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RC 31 
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'I 



MEMORANDA 



FROM THE 



CLINICAL COURSE OF mSTRUCTION 




Medical Department University of Louisiana 



Kf^published from the Nev) Orleans Journal of Medicine, for the benefit of the 

Class of 1867-8. 



Art. I — Surgical: By Prof. Warren Stone. Eeported by 
Warren Ston^, Jr., M. D. 

The cases wliicli furnished material for the clinics of the Profes- 
sor of Surgery in the University, during the past session, proved, 
in the result of the treatment carried out, to be so eminently 
illustrative of principles emanating from purely practical observa- 
tion, that even an imperfect review, it is to be trusted, AYill not 
be entirely unprofitable. It has been determined to avoid, 
as being both unnecessary and tedious, any detailed account of 
each separate individual case, but rather to select certain classes 
of surgical diseases, of which there were presented a snfiicient 
number to justify the estabishment of some fixed principle. In 
addition to the material which was brought before the class, as 
selected from the surgical wards approi^riated for the use of the 
University, there came under the Professor's notice, as well as my 
own, a number of out-patients of such deep interest in a practical 
way, that it has not been deemed inapju-opriate to incorporate a 
mention of them in the report. 

The number of cases of hydrocele treated were, in i^roportion, 
unusually large. The tumor, especialh', when of considerable 
size, was tapped, and the patient discharged with instruction to 
return as soon as the sac had become distended by the serous 
secretion to about half its former size. Then the operation for 



\ 



2 CLINICAL MEMORANDA—SURGICAL. "^^"^^ 

the radical cure was immediately performed. The object of first 
adopting what is termed the palliative treatment was two- 
foUl, viz : that of affording the patient the very slim chance of 
the dropsy not returning (and I may here remark that in no in- 
stance did this occur), and secondly, that of rendering the opera- 
tion for the radical cure the more certain j for, when the remedial 
fluid is injected into sacs, from which a large quantity of water has 
just been drawn, its walls are, by the contraction of the dartos, 
thrown into so many complicated folds that it is quite uncer- 
tain whether, even by the most strenuous exertions, it suc- 
ceeds in exerting its influence over the whole surface — which is 
absolutely necessary for complete success. 

Xow as to the fluid used for this radical cure. In every case 
nothing but the compound tinct. of iodine, i?wre, was used, and with 
invariable success. A small trocar was inserted in the ordinary 
manner, every drop of the water carefully drawn out, and, by 
means of a proper syringe, as much of the tincture as the size of 
the sac required was injected. Xo dilution was ever found ne- 
cessary. Indeed, as above mentioned, it was scrupulously avoid- 
ed by thoroughly emptying the tumor of its contents. The fluid 
once in, with the finger upon the end of the canula to present its es- 
cape, a most thorough kneading of the scrotuna was practiced, so 
that every part of tunica vaginalis might be subjected to its influ- 
ence. This done, the fluid was allowed to escape, and the patient 
directed to suspend the scrotum and keep himself at rest for several 
days. — During the succeeding twenty -four or thirty-six hours, the 
scrotum generally swelled, varying in size in different cases, some- 
times almost as large as before the operation. This swelling 
generally lasted from two to four, or even five days, and then gra- 
dually subsided, leaving the patient perfectly cured. As a rule, 
the inflammation excited never progressed beyond the in-oper 
limits ; when it did, the simplest means always subjugated it. 

Chloroform was never used in the operation, the pain attend- 
ant upon it not seeming to justify it. By holiling the canula in 
such a direction as to avoid throwing the current npon the cord, 
that seveie pain running up its course and producing a sense of 
l)rostration was avoided, and the i)atient sin)i)ly subjccU'd to a 
feeling of lK*;it in tlie scrotnni, which ;ihv;iys i)roved to be per- 



CLINICAL MEMORANDA.— SURGICAL. 



3 



fectly bearablCj and rarely ever lasted more tlian half an hour at 
the farthest. 

As to the question whether the Injection should be used when 
the testicle is in a state of chronic or even sub-acute inflamma- 
tion, or whether means to reduce either stages of the inflamma- 
tion should be adopted before its use. Although in quite a large 
proportion of the cases both chronic and sub-acute inflammation 
of the testicles existed, this complication was not considered an 
impediment to the operation indeed I will say, that instead of 
its producing any unfavorable results, the effect upon the organ 
seemed to be, if anything, beneficial ; it always appeared in a 
marked manner to hasten return to the natural state. It is 
true that in a certain number of these cases a gentle mercurial 
course was adopted, but the rapid change from disease to health 
contrasted so favorably with that occurring in simple chronic un- 
complicated cases of inflammation of the testicle, that it does not 
seem injudicious that we should allow a good share of the benefit 
to be appropriated by the iodine injection. 

There occurred but one case of hydrocele of the cord. This • 
happened with au old man aged 70 years, who was also suffer ii g 
with the same trouble of the tunica vaginalis. Both tumors weie 
punctured at the same time, and injected as above mentioned 
with perfect success. 

Organic strictures of the urethra were treated on the plan of 
gradual dilatation. In some few, but very few, cases of old, in- 
dolent strictures, with but little sensibility, forcible dilatation 
was practiced ; but in every case of this sort the subsequent use 
of the smooth, conical-pointed, metallic bougie was never neg- 
lected, it being considered absolutely necessary for the perma- 
nent cure. But, as I have said, such cases constituted a very 
small per cent, of those which came under observation, I can 
therefore assert that the rule of treatment was that of gradual 
dilatation. 

Now as to the manner of using the instruments, the rapidity 
with which the size was increased, and the little adjuvants used. 
Where the stricture was so tight as to offer considerable resist- 
ance to the passage of the smallest size, and withal sensitive, no 
forcible effort to effect a passage was made. The patient was put 



4 



CLINICAL MEMORANDA.— SURGICAL. 



upon equal parts of tartar emetic and niorpliia in the evening, 
and the medicine pushed until nausea ensued ; an early breakfast 
ordered, and the same course begun several hours after the meal ; 
a warm hip-bath administered and then the attempt made. With 
tliis course a passage was almost always effected. Once through, 
the same instrument was introduced every other day, nntil it was 
found to pass without difficulty and without giving pain to the 
patient. A size larger was then used, but with great care, proper 
attention being paid that no undue amount of pressure should be 
made upon the strictured point. It was always kept in view, the 
amount of wedge power exerted by the instrument, and its com- 
paratively easy passage was not permitted to influence a too rapid 
increase in the size. The stream of urine was frequently observed 
to be gradually increasing in size under the use of the same in- 
strument, when either at the patient's solicitations or our own 
impatience an inadvertent change would, by making unwholesome 
pressure, produce bad effects and throw the case back seveial 
weeks. In those cases of excessive irritability^, prone to engorge- 
ment, etc., much advantage was derived from injections of solu- 
tion of nitrate of silver, ranging in strength trom five to ten, 
fifteen or even twenty grains to the ounce of water. 

Where the patient was forced to rise a number of times during 
the night to urinate, and this accompanied with pain, much relief 
was obtained from either an opium suppository or an anodyne 
enema administered at bedtime. In such cases I will also men- 
tion the great assistance afforded by the use of the tartarized an- 
timony and morphia, administered as before mentioned. In a 
few cases of very recent strictures mercury, given in small quan- 
tities and pushed until its specific effect was obtained, seemed to 
do good. 

There were several cases admitted into the wards suffering 
from stoppage of the urine, as a result of sudden engorgement of 
an old stricture, resulting from excess in drinking, or venery, or 
unusual exposure to the weather. Upon inquiry, it was found 
that they all had had strictures of gonorrhoeal origin for several 
years, had been under treatment at various times, but from that 
peculiar improvidence that seems to characterize certain classes, 
had as often abandoned it, being content so long as the bladder 



CLINICAL MEMORANDA.— SUKGIGAL. 



5 



could be emptied. In these cases, instead of making efforts as vio- 
lent as they would have been futile, to force a catheter into the 
bladder, the following means were adopted : All instrumental in- 
terference was avoided ; tartar emetic, hip-baths, etc., were used, 
and in every case in a short while the urine began to dribble. In 
a few days the stricture recovered its former calibre, and was in 
the best condition for the treatment of gTadual dilatation. 

In several instances there came under observation, pa- 
tients who, suffering as above mentioned, had been subjected 
to the violent use of instruments before admission into the hos- 
pital, thus offering an opportunity of establishing a comparison. 
In the first place, it was seldom that a passage was effected, and 
even in those in whom catheterism was successful, the same 
stopi)age occured, and forced them into the hospital, when the 
course just mentioned was adopted, and permanent relief was al- 
ways secured. 

As to the length of time that the instrument, when used, was 
allowed to remain. If the first unpleasant sensatii)n accompany- 
ing its introduction increased to positive ijain, it was always im- 
mediately withdrawn, it having been observed to be productive 
of positive evil, even when the patient gave assurance that 
though painful it was bearable. If no pain was complained of, 
or rather if the first painful sensation disappeared, it was allowed 
to remain for fifteen, twenty, or thirty minutes. The practice of 
keeping the instrument in for twenty -four or thirty-six hours was 
not practiced, on the contrary, it was most earnestly deprecated. 
Patients were never discha^^ged without being particularly in- 
structed as to the very strong probability of a return of their 
malady, and were ordered a iiroper sized instrument to be used 
by themselves, as soon as they observed any change in the calaber 
of the stream of urine. Little difficulty was experienced in 
teaching them the use of the instrument. 

Ko case occurred which called for external division of the stric- 
ture, generally called Syme's operation. The efficiency of this 
operation when followed by the subsequent persevering use of 
the bougie, is fully recognized, and had any cases to wliich it is 
peculiarly adopted presented themselves, it would have been per- 
formed without hesitation. 



6 



CLIlSriCAL MEMOEANDA.— SURGICAL. 



All tlie cases of strictm-e were of gonorrlioecal origin, ami for 
the most part situated in the membranous portion of the urethra. 
There was but one case of traiimatic origin. This happened with 
a carpenter who fell astride a narrow board and ruptured the 
urethra. As is always the case, his stricture proved the most 
obstinate, but was finally overcome. 

Fistula in ano (comx^lete), was treated by the knife, especial 
care being taken that the original opening in the bowel should 
be found, and not an artificial one made by the point of the probe, 
which is quite an easy matter, unless proper care is observed. 
This finding of the original opening in the bowel, and cutting 
from it through the sphincter muscle was looked upon as abso- 
lutely essential to the cure. Several cases were admitted that 
had been operated on previously without success, — and this mis- 
hap was attributed to this piece of neglect. It was never deemed 
necessary to cut higher than the opening in the bowel, even when 
the sinus was found to have burrowed some distance above it. 
Xo difficulty ^as experienced in any of the cases — the wound 
being so treated as to cause it to fill from the bottom — rapid re- 
covery took place. 

Haemorrhoids (internal) were treated by the ligature. In 
applying the ligature it was made an object to place it as high up 
as possible — even in the largest sized haemorrhoidal tumors, it 
was never found necessary to apply more than three, scarcely 
ever four ligatures. When the slough came off, if any points of 
ulceration were left, causing the patient uneasiness and much 
straining at stool, relief was generally obtained by injections of 
one part of Labarraque's solution of chlorinated soda to eight or 
ten of water. 

Syphilis in its various stages occurred in large proportion. The 
primary sore, when soft in nature, was always treated as a simple 
local disease. The application of caustic with the idea of destroy- 
ing the virus was never used, it being considered useless. ^Yhen 
used at all, it was upon the same principle that would have sug- 
gested it in any other ulcer. 

Buboes when suppurating, were freely opened as soon as pus 
was detected, as would have been done in any ordinary abscess. 

In the larger proportion of cases with soft chancres no con- 



CLI>'ICAL MEMORANDA.— SUEGICAL. 



7 



stitutioual symptoms manifested themselves, but in some there is 
no question that such did occur. Xott, whether the chancre was 
at first indurated, and then before the patient came under ob- 
servation changed its character, cannot be positively determined, 
for very little reliance can be placed upon the testimony of any 
patient, much less such as come to the hospital for treatment. 
However, it does seem rather singnlar that in this country, where 
indurated chancres ha^•e gotten to be almost the exception, there 
should be so many suffering from the disease in its secondary and 
tertiary forms. But, as no discussion on this point is contem- 
plated, I vrill simply say that be the matter as it may, one thing 
is certain— observation has shown that in the true, genuine soft 
chancre, mercury, the great syphilitic specific, so-called, not only 
aggravates the local trouble, but does not give any immunity 
from constitutional effects, if such are to ensue. Several op- 
portunities were afforded for observing its sad effects, and they 
were the very worst cases we had to treat. Such applications as 
the nature of the ulcer seemed to require were used upon the 
same principle as would hold good in any simple ulcer. 

There were only two cases of indurated chancre admitted. 
Both* were seen at the onset of the disease. In each case mer- 
cujry was used until gentle pytalism ensued, and then the iodide of 
potassium. The glands in the gToin swelled and were peculiarly 
painful to the touch, but did not suppui^ate. One of the two 
cases was detained in the hospital, by an attack of fever, for 
several weeks after the chancre had healed and the buboes sub- 
sided. Although, as I have said, his case came under treatment 
almost immediately after the disease manifested itself, six weeks 
after he presented evidences of constitutional symptoms in the 
shape of quite a number of coppery blotches on his forehead, a 
little beyond the roots of his hair. In less than a week the same 
appeared on his chest and arms. It was believed at the time, and 
the same opinion is still entertained, that it was reasonable to 
attribute this to his illness, which was so severe as to lower his 
vitality very much, thus depriving nature of her ability to throw 
oft' the poison, with which power, when properly and judiciously 
assisted, she is fully credited. By taking means to restore his 
general health, and at the same time using mercurials and the 



8 



CLmCAL MEMORANDA. 



— SUEGICAL. 



potasli salts, with great care and in small quantitieSj he ybtj soon 
was able to leave the hospital without any evidence whatever of 
syphilitic taint. 

Secondary syphilis manifested itself in such a variety and in so 
many complicated forms of eruption, that it will only be spoken of 
in general terms. Every patient who was admitted with an erup- 
tion on the skin, scaly, pustular or otherwise, and who had at 
some time had a sore on his penis, was sure to answer, when 
asked what was the matter, that he had " secondary." If the 
character of the eruption excited suspicion, and upon thorough 
examination it was found that it had shown itself during a period 
not exceeding six months subsequent to the primary sore, and 
further that it had made its appearance first upon the forehead 
and then gradually extended to the trunk and limbs, it was 
looked upon as constitutional syphilis and so treated. In making 
the examination and arriving at a conscientious conclusion, great 
stress was laid, in the first place, upon the time that had elapsed 
between the first ai^pearance of the chancre and the occurrence of 
the eruption. If it exceeded six months, it was not looked upon 
as syphilitic ; in the second, which part of the body was first 
attacked — if the forehead and then the limbs and trunk, it was 
considered syphilitic, other things being equal. I have repeated 
these two points of diagnosis that the importance with ^^hich 
they are invested might be brought forward more i^rominently. 
So much value was placed upon them that, when the eruption 
was so unquestionably characteristic as to challenge all doubt, 
and the patient's history did not correspond with what has been 
above stated, he was freely credited with a misstatement, arising 
either from ignorance or want of observation. 

To speak in general terms of the treatment adopted in this form 
of syphilis, I will say, that mercury seemed to agree far better in 
the scaly form of eruption than in the pustular j in fact it was 
rarely ever used in the latter. In either case, however, special 
pains were taken to restore the general health, it being considered 
absolutely necessary for any iiermanent result. Whenever mer- 
cury or iodide of potassium was used, it was .administered in such 
a way as not to disturb the general functions. 

As has been above mentioned, the system was considered per- 



CLINICAL MEMOEANDA — SURGICAL. 



9 



fectly capable, in a large proportion of cases, of ridding itself of 
tlie poison, if proper care was taken that the machinery worked 
in perfect harmony. With this idea in view, many cases of un- 
doubted constitutional syi)hilis were treated and cured without a 
dose of what is generally deemed specific remedies. In those 
cases where neither mercury or the iodide of potassium was 
deemed expedient, the chlorate of potassa combined with the 
muriated tinct. of iron was used with the best results. The 
potassio-tartrate of iron also answered an excellent purpose. 
Good diet, cod-liver oil, malt liquors, the hypophosphites, and 
everything calculated to place the general system at the proper 
standard of health. 

As for the tertiary form of the disease, 1 will simply mention 
it as manifesting itself in the shape of periosteal inflammation. 
A large number of cases of this kind were treated and in the fol- 
lowing manner : From a grain, to a grain and a half of calomel, 
night and morning, combined with a small proportion of opium 
was administered until the gentlest possible specific eiiect was ob- 
tained. The iodide of potassium was then given in doses varying 
from two a half grains to five grains, three times a day, either 
combined or not, as the case seem_ed to require, with some tonic. 
The dose of the iodide of potassium was never increased beyond 
five grains. When the tenderness of the gums subsided — the 
iodide of i)otassium being continued— a grain, sometimes half a 
grain, of calomel was given at night, aiid kept up until slight 
pytalism again ensued. It was then stcpi^ed, only to be repeated 
in due time. This simple plan was continued until every evi- 
dence of disease disappeared, and in every case the result proved 
to be permanently successful. The iodide of potassium was never 
used in the large quantities that have been advised for the relief 
of the severe nocturnal pains which accompany this form of in- 
flammation. A large iiroportion of the patients who came under 
observation had been subjected to the use of these large doses of 
the iodide, but while confessing that they derived some relief 
from their pains, acknowledged that it was but temporary, and 
much to the detriment of their general health. 

It was more especially in this form of syphilitic inflammation 
that mercury seemed to exert its most striking and best effects. 
2 



10 



CLIXICAL MEMOKANDA.— SURGICAL. 



Patients who, in outward appearance, seemed the last subjects of 
mercury — pale, emaciated, scarcely able to walk, dreading nigM- 
fall with the same degree of horror as the dying sinner his lot in 
eternity — when put upon and under the use of small doses of 
calomel, woukl, as it began to exert its influence, improve in 
color, nutrition and strength; while the severe nocturnal pains, 
which even the most immoderate use of opium failed to control, 
disappeared almost entirely. 

With the idea already referred to, that the syphilitic poison 
sapped the constitution, just as malaria or any other intangible 
poison does, due attention was paid to the restoration of the 
general health. 

XoLles, when soft, even giving a sense of fluctuation that 
seemed to indicate the presence of pus, were never opened; it 
having been observed that under the treatment above mentioned, 
they generally took much better care of themselves when not 
troubled with the knife. 

Blisters were never used, nor was the tincture of iodine — 
neither was looked upon as beneficial, although they might be 
harmless. What seemed to give the most relief, was the envel- 
oping of the affected part in a towel previously soaked in cold 
water, and then covering this with a dry one, the whole to remain 
on during the night. In some cases a teaspooiiful of laudanum 
was poured upon the wet towel, and did much towards calming 
the pain. 

To sum up the whole in a few words, those suffering with con- 
stitutional syi)hilis were looked upon as being impregimted with 
a poison, which was only to be permanently expelled by the 
maintenance of the powers of nature, and not by the indiscrimi- 
nate use of specifics. Whenever it was deemed expedient to use 
either mercury or the iodide of i)otassium, it was given in such 
quantities and guarded by such scrupulous precautions, that no 
interference with the natural functions should occur. 

In selecting for use from the salts of mercur\^, preference was 
given to calomel, it being considered more certain, safe and 
cnpable of being bL-tter managed. Where a slow, gradual effect 
was desired, the bicliloride was sometimes used with very good 
effect, ill d().s(?s varying from a sixteenth to a tbirty s:cond of a 
grain two or three times a dny. 



CLINICAL MEMORANDA.— SUKGICAL. 



11 



Gonorrlicea, when seen at the very onset, was treated with 
balsams combined with appropriate mild Injections. If some 
days had ehipsed, the balsams were never resorted to. The 
treatment consisted simply of injections, proper attention of 
course being paid to the general condition. Strong injections 
were never resorted to. The one most generally used consisted 
two grains cf tannin, and a drop of dilute nitric acid to the ounce 
of distilled water. 

Gleet, when of long standing, was treated hj injections of solu 
tions of nitrate of silver, varying in strength from five to filteen- 
or twenty grains to the ounce of water, tonics, the muriated tinc- 
ture of iron, etc. The solution was injected by means of a cath- 
eter syringe, having one small pin hole at its very extremity, and 
not on the side, as is generally the case. The point of irritation 
was generally found to be about the prostatic portion of the 
urethra, and to that spot a few drops of the solution were applied 
every day. As a rule, not more than three or four injections 
were required. 

There were treated fractures of the humerus, ribs, femur and 
tibia. Fractures of the humerus were treated simply by the ap- 
plication of pasteboard splints on the oiiter and inner sides of the 
arm, the hand resting in a sling, the elbow allowed to hang free, 
so that proper extension might be made, i^o trouble was expe- 
rienced in obtaining good results. 

Fractures of the ribs were treated by the firm application of a 
broad strip of adhes've plaster around the thorax, to control the 
movements of the fragments, by securing, as for as was possible, 
abdominal respiration. Several cases had pleural complications, 
but the ordinary treatment soon disposed of it. 

Fractures of the femur, when occurring in the lower two-thirds 
of the bone, were treated by Liston's straight splint, modified by 
a small horizontal foot-piece placed at right angles to it ; from 
which extension was made by means of adhesive plaster attached 
to the leg, counter extension being exerted by an ordinary 
perineal band. In fractures of the upper third Smith's anterior 
splint was used, with excellent results ; in fact, the greatest pre- 
ference was given to this splint in fractures of this region. Thp 
proper amount of extension was always obtained, the fragments 



12 



CLIKICAL MEMORANDA.—SURGICAL. 



kept in the best apposition, and more comfort afforded the patient 
than was ever obtained by any other apparatus. One case espe- 
cially, Avith a distinctly oblique fracture a little above the middle 
of the upper third, recovered with so little shortening, that, with 
the sole of the boot on the affected side a shade thicker, his lame- 
ness is scarcely perceptible, except by the closest scrutiny. 
Starched bandages were not used much, except where it was of 
real importance that the patient should have exercise in the open 
air. 

Fractures of the tibia were, for the first week or two, treated 
by what might be called a pillow splint. This consisted of a 
moss pillow well stuffed, and so scooped out as to leave a place for 
the limb to rest in, ordinary wooden splints being x)laced on each 
side of the pillow. The whole was made firm by tying it up 
with pieces of tape or bandage. This was found to be a 
most excellent and comfortable apparatus. It was used in pre- 
ference to the fracture-box for this reason : it is light, and when 
the patient moves the limb, the whole moves together, and there 
is no jostling of the fractured ends, as would be the case in the 
cumbersome fracture-box. In due time the starched bandage and 
pasteboard p]>lints were applied, and crutches furnished. In none 
of the cases did there appear any disposition to much displace- 
ment of the fragments. As a rule, the stereotyped i)lan of soak- 
ing the fractured limb either in cold water or some evaporating 
lotion, and continuing it for days, was not adopted. It was con- 
sidered in a large majority of cases unnecessary, if not even detri- 
mental. A certain amount of inflammation is to be looked for ; 
upon it depends the cure 5 it is not apt to progress beyond the 
j)roi)er limits, unless the injury to the soft parts be more serious 
than is ordinarily the case in simple fractures, or there be some- 
thing in the patient's system that predisposes to excessive action ; 
and it seems obvious that means calculated to subdue that proper 
action which nature in her providence sets up, cannot do good. 
But even if no serious material harm is avoided by abstinence 
from lotions J at least the patient is savetl the blistering and sub- 
sequent soreness of the skin which so frequently follow their use, 
rendering the application of th<3 necessary s^^lints uncomfortable 
if not positively painful. 



CLIXICAL MEMOEAXDA.— SURGICAL. 



13 



^Tien from nervous irritability the muscles of the affected limb 
became rebellious, and were constantly twitching in every direc- 
tion, no effort at forcible extension was made, it being' considered 
l^erfectly futile. The limb was placed, free from any apparatus, in a 
position most comfortable to the patient, and attention paid to 
the general condition. All the means calculated to equalize the 
nervous system were assiduously resorted to, and not until thie. 
object was attained was mechanical interference resorted to. 

Generally the patients that came into the hospital were of that 
class whose vital powers were not at a very high standard. Al- 
though apparently stout and vigorous, when the system was called 
upon for reparative action,— nature gave ample testimony as to 
the heavy drafts upon her storehouse, to pay the penalty of their 
various excesses and reckless exposures. These patients, when 
suffering from fractures, were watched very closely, and if in 
from three weeks to a month that degree of union which should 
take place in that time had not occurred, means were taken to 
promote it. It was not waited for to see if perchance it might 
take place. Small blisters, repeated in rapid succession, were ap- 
plied over the fractured point. Cod-liver oil, the hypophosphites. 
frequently the sin:ple phosphate of lime, malt liquor, etc., were 
administered. Under this course ossificatio.] always took ])lace 
rapidly, in point of fact, in some cases, it appeared to do so more 
rapidly than generally occurred under more favorable circum- 
stances. It is cpiite certain that, had such patients been passed 
by carelessly, they wo.Jd have remained for months without 
union, the long and tedious confinement lessening every day their 
chances for recovery. 

There was but one case of compound fracture treated. This 
was of the tibia in its lower third, and, though, simple at first, it 
became compound, owing to the sloughing of the soft parts over 
the fractured point. It was treated at first with the pillow 
splint ; then the excessive discharge necessitated the use of the 
fracture-box with bran, — and subsequently the starched bandage. 
Prefect union has taken place, and though no effort at extension 
was made, there will be but little deformity. 

This case was one of the deepest interest, not so much on ac- 
count of the fracture as the serious complication which accom- 



14 



CLIKICAL MEMOKANDA.— SURGICxlL. 



panied it. He had been an habitual drinker for many years, and 
bad on two previous occasions bad slight attacks ot delirium 
tremens. For two weeks before the receipt of his iujury, he had 
been drinking to great excess, and had taken but little nourish- 
ment for three or four daj^s, almost living upon alcohol alone. 
He was seen the morning after admission into hospital, having 
been brought there during the night, — and immediately ordered 
twelve grains of calomel and bicarbonate of soda, in broken doses 
of two grains every half hour. The next morning it liad acted so 
very freely that it was not considered necessary to administer 
the usual saline, as sufficient disgorgement had taken place. 
Beef-tea, eggs, milk, etc., were given, and he took quite an allow- 
ance with apparent relish. Notwithstanding this favorable turn, 
he manifested towards evening symptoms of delirium ; bnt they 
were mild, and as he had been thoroughly disgorged and had taken 
nourishment, it was not feared that it would assume a serious 
form. Of one grain of tartarized antimony and morphia in four 
ounces of camphor water, a tablespoonful was ordered to be given 
every two hours. Although the first three doses seemed to quiet 
him and promised the securing of a good night^s rest, he grew 
gradually worse during the night, and by morning was so per- 
fectly furious as to require the use of the straight jacket. When 
seen at the morning visit, at nine, A. M., his pulse could scarcely 
be counted, and despite his shackles, it required the united 
strength of three stout men to prevent the entire demolishment 
of his injured limb. 

The solution of tartar emetic and raornliia was stopped, and the 
inhalation of chloroform, carefully guarded, was resorted to, but 
only to be almost immediately abandoned, as it threw him into 
violent spasms and rendered him nearly pulseless. He was then 
at once ordered an ounce of tinct. digitalis, of w^hich a teaspoon- 
ful was to be given every two hours, until sleep was procured. 
It was neck or nothing with him, and there was no hesitation felt 
in giving such directions. He was seen at eight o'clock in the 
evening, just after the sixth teaspoonful had been given. His 
pulse had subsided remarkably, being scarcely 90, skin and 
tongue pleasantly moist, and his mind much clearer. He was 
perfectly docile, and answered questions intelligently. He said 



CLINICAL MEMORANDA.— SURGICAL. 



15 



he felt an inclination to sleep, and directions were given to his 
nurse to discontinue the digitalis so long as he remained quiet, 
but to resume its use as before should he evince any of his former 
symptoms. At half-past eight he fell into a pleasant slumber, 
which lasted until towards morning, when he awoke, as the nurse 
stated, quite restless, and was given the seventh dose. When 
seen at nine, A. M., he was in a calm, natural sleep, with a good, 
full, natural pulse, and so continued until late in the evening j 
then again becoming restless and wayward, the last remaining 
dose was given. This finished the business. His sleep during 
the night was undisturbed, and lasted until the afternoon of the 
next day, when he awoke perfectly rational and called for nourish- 
raent. His pulse could not have been better, the skin was i)leasant, 
tongue moist, bowels sufficiently free, and the urinary secretion 
in perfect order. From this time no trouble was experienced 
with him. Under the most favorable circumstances his com- 
pound fracture could not have done better. Special reference 
has been made to this case, to bring prominently forward the un 
doubted good effects ot the digitalis, as well as its perfect safety 
in all cases of a similar nature.. 

Of dislocations, there occurred cases of the humerus, hip 
and jaw. There was but one variety of dislocation of the hume= 
rus, viz : downwards into the axilla. The majority of the cases 
were recent, but there was one case of a month's standing, 
one of five weeks, one of six weeks, and one of three months 
and twenty days standing. The following was the method of re- 
duction : 

The patient was first put upon the use of tartar emetic until 
g( ntle nausea ensued, then chloroform was administered until 
perfect relaxation was obtained. He was placed in a sitting pos- 
ture,, either in a chair or on a low couch j a wet towel was so 
bandaged to the arm as to leave a loop for the assistants to make 
extension ^ a sheet was put around the chest, by means of which 
counter extension could be exerted ; and the operator proceeded 
with his knee in the axilla and the ball of the thumb pressed 
firmly against the acromion, the foot resting against the edge of 
the chair or couch. As soon as the proper amount of relaxation 
was obtained, the assistants were directed to make a slow, steady 



16 



CLINICAL MEMORANDA.— SUEGICAL. 



pull, aDd when tlie contraction of tlie opposing muscles was over- 
come, by making use of the humerus as a lever, the knee being 
a fulcrum, the head of the bone was thrown into its natural posi- 
tion. This plan of reduction was the only one resorted to. The 
facility with which the scapula was held firm by the hand upon 
the acromion, and the immense lever power afforded by the shaft 
of the bone, were considered recommendations sufficient to accord 
it the preference. 

The onl3^ case in which the pulleys were used was the one of 
nearly four months' standing. The same method of reduction 
was employed in this case as in the others, except the mechanical 
substitute, and with perfect success. 

The arm was generally kept in sling for three or four days— 
not longer ; then the patient was directed to make cautious use 
of it. It was found much better to have them make early move- 
ments of the joints. In none of the cases was there any subse- 
quent inflammation, except in the old case of four months j but it 
was of a mild character and only lasted a short while. 

There was but one dislocation of the hip, upwards and back- 
wards on the dorsum. This was of several weeks' standing, and 
notwithstanding anchylosis of the knee-joint, was reduced by 
manipulation. It is true the knee had not anchylosed in the 
straight position, but was slightly flexed and twisted a little out- 
wards. This rendered the manipulating process somewhat more 
easy than it would have been otherwise. Manipulation was most 
emphatically advocated, in preference to the pulley, in this form 
of dislocation, no matter of how long standing. It was consid- 
ered that much more force in the proper direction could be ex- 
erted and much less violence committed. 

There was also but one case of dislocation of the jaw. It was 
of seven week's duration, and was reduced in the ordinary way, 
by phicing' the thumbs at the roots of the coronoid jn^ocesses, 
pressing downwards and backwards, and elevating the chin with 
the fingers. The accident had occjrred during the act of vomit- 
ing, and the patient was in a region where surgical assistance 
could no J be obtained — until a month after it happened. An ef- 
fort at niduction was then made, but without success, when she 
api)lied to me for relief. She remained in town for three days 



CLINICAL MEMOEAXDA — SUEGICAL. 



i: 



after the operation, and then was forced to return to tlie country. 
Having received proper directions as to the necessary precautions 
to be observed, and not having been heard from since, it is pre- 
sumed that no further trouble was experienced. 

There were no cases of compound dislocation treated in the 
hospital, but one interesting case of compound dislocation of the 
ankle came under my charge outside, of which brief mention will 
be made. 

The i^atient, a stout, vigorous young man, aged about twenty 
years, in jumping from a runaway horse lighted ui^on a cobble 
stone, and so turned his left foot as to throw the tibia out of joint 
and through the skin. He was seen about half an hour after the 
accident. The foot was almost at riglit angles to the leg, the 
bone protruding for several inches. Notwithstanding the severity 
of the injury, he did not manifest a correspondiLg degree of shock, 
and beiug in full vigor of health, the case was undertaken with 
cheerful anticipations, which, it is a pleasure to state, the result 
has realized. Chloroform having been administered, gent.e, 
steady extension was made by the assistants, while with the 
handle of an ordinary silver spoon, sUpped carefully under the 
portion of skin overlapi)ed by the bone — its shaft resting upon the 
bone — and used as a lever, the reduction was effected without 
the slightest dif&culty. 

The wound appeared to be so cleanly cut, and the j^atient was 
in such good condition, that an effort was made to secure its heal- 
ing and convert the injury into a simple dislocation, by caret ully 
bringing its edges together. The ordinary means to keep the 
foot in x)roper position were employed, anel to control auy inflam- 
matory action constant irrigation was kept up over the joint. 
Although destructive inflammation was arrested, the soft parts 
over the internal malleolus proved to be so severely contused that 
quite a slough came away, exposing to a great extent the cavity 
of the joint, thus disappointing our fii'st hopes. Pus subsequently 
burrowed up the limb and with the most remarkable rapidity — it 
was fortunately confined to the subcutaneous cellidar tissue. 
Early and free incisions were made for its escape. Notwithstand- 
ing this it still tended to progTCSS upwards, and it was thought 
that material aid in arresting it was afforded by the use of com- 



3 



18 



CLINICAL MEMORANDA.— SURGICAL. 



presses confined by adhesive jjlaster. At tlie present writing, 
seven weeks from tlie date of injury^ the patient is doing excel- 
lently well. The heads of ankle bone are perfectly intact, and he 
will undoubtedly have a very good foot. In connection with this 
case, I would call special attention to the manner of reducing the 
protruding bone ; which, it is hardly necessary to state, is quite 
as api)licable to compound fractures with similar protrusions. 
By adopting the method employed in this case, there will rarely, 
if ever, be an}- necessity for sawing otf the exposed portion of 
bone or slitting the skin. 

There were three amputations performed— one of the thigh, one 
of the leg, just below the knee, and one secondary amputation of 
the leg, for the relief of an ulcerated stump. 

The amputation of the thigh was performed for bony anchy* 
losis of the knee-joint, in a bent position, with subluxation of the 
femoral condyles inwards. The joint had been laid open several 
years previous by a heavy blow with a large broad-axe, which 
probably severed the ciucial ligaments, Xot receiving very strict 
attention after his mishap, he became the -victim of a deformity 
which rendered his limb a constant burden. His solicitations to 
have it removed were most earnest, and, after due deliberation, 
amputation just above the knee was determined on in preference 
to any conservative means. It was considered that in his case 
an artificial limb would be of far more service than the natural 
one, if i)erchance any such attempt to preserve it should have 
succeeded j and furthermore, that the risk would be no greater, 
if as great ; for in the present impoverished condition of the hos- 
l)ital, the dangers of long confinement, extensive su|)puration, 
etc., are not to be carelessly overlooked. The antero-posterior 
flap operation was performed, and he did excellently well tor three 
weeks after, when symptoms of pyiiemia were manifested as sud- 
denly as they were unexpected, and in spite of every endeavor 
to save him, he died during the fourth week. Post-mortem ex- 
aminatiou revealed the presence of pus extending for several inch- 
es up the cavity of the bone, and also infiltrated in its cancellated 
structure. The apex of one lung was pretty thoroughly studded 
with tuberculous deposits, otherwise his whole organism appeared 
to be in a healthy conditicm. 



CLINICAL ME:yiOHANDA.— SUEGICAL. 



19 



The amiJiitation of the leg was performed for an ulcer, extend. 
ing from tlie ankle to witliin a few inches of the tuberosity of the 
tibia. lN"o time was lost in determining upon the propriety of 
amputation. The ulcer was painful, dischargiug large quantities 
of thiUj ichorous matter, and although the patient was pale, ema- 
ciated, with a rapid, feeble pulse, without appetite, it was speedi- 
ly observed, that any means to build him up, however well- 
directed, was seriously overbalanced by the pain and excessive 
drain to which he was hourly subjected, and only involved the 
loss of valuable time. 

The borders of the ulcer were so defined as to admit of the fiap 
operation, but. as has always been the practice in the wards, pre- 
ference was given to the circular method, as giving the best 
stump, and securing the patient against the evil effects which 
have so often been observed to follow the flap operation. TTlien 
carried from the operating table and placed in his bed, he had a 
much better pulse than before the operation, and from this time 
began his improvement, which was uninterrupted. In due time 
he was discharged, in better health than he had been for eighteen 
months. He had been relieved from an incubus which was 
weighing him down, and it did seem that nature, truly thankful 
for the good riddance, rallied her forces with an alacrity and 
vigor scarcely to be looked for. But I will state, that with all 
the apparent disadvantages, such cases, as a rule, do far better 
than when the same extreme measures are taken for the relief of 
patients in vigorous health, suffering from the effects of destruc- 
tive injuries which have produced a sudden and severe shock to 
the system. If an opportunity to amputate while the patient is 
under the shock be offered, no better period could be chosen. 
By refraining from annoying, by the indiscriminate pouring in of 
alcoholic stimulants, the stomach, which in this condition of 
shock is quite uncertain as to absorbtion, while it may be even 
disturbed, and instead, using an enema of carbonate of ammonia 
just as chloroform begins to manifest its effects, the object de- 
sired is obtained much more speedily, more satisfactorily, and 
last, but not least, with much less detriment to the patient. With 
this simple precaution, the addition of the shock of the operation 
to the already existing shock of the injury, amounts to but little 



20 



CLmiCAL MEMOEANDA.— SIJEGICAL. 



if anythino', and tlie patient is placed in the best condition for 
recovery. However tins opportunity is seldom or ever afforded. 
The patient is rarely ever seen until several liours after the re- 
ceipt of the injury, when reaction has set in. To attempt opera- 
tive procedure at this stage would be as inhuman as the casting 
loose the drowning man's grasp upon the friendly shore, which 
his frantic efforts liad enabled him to reach. Far better to wait. 
T\'hen suppuration has fairly ensued, and the drain seems to 
counterbalance the efforts of nature, which are supposed to have 
been, in the meanwhile, i)roperly sustained, then amputation can 
be resorted to with the same degree of confidence as was telt in 
the case of ulcer just cited. 

The x)atient who presented himself for treatment for ulcerated 
stump, had I ad his leg amputated daring the war on account of 
gunshot wound. The flap operation was performed, and although 
made perfectly well, the large muscles of the calf, which form the 
greater portion of the flap, by their constant contractions, kept 
him in a state of perpetual uneasiness. The skin over the tibia 
gradually thinned and eventually ulcerated. For this reason es- 
pecially is preference always given to the circular method or else 
the oval skin flap. Notwithstanding the patient was, to all ap- 
pearances, stout and healthy, the operation was undertaken with 
a degree of reluctance which elicited every care and precaution, 
it having been observed that the procedure subjects such patients 
to the same risks as primary amputation ; indeed, in quite a num- 
ber of instances it has seemed to be greater. It is impossible to 
determine how long it takes the system to recover from the deep 
impression made upon it by the severe injury and subsequent 
operation, and in this case ample testimony was given as to the 
correctness of this practical observation. Although he recovered 
with an excellent stump, he sufl'ered \ery much, and required 
the most careful and constant watching for several weeks. 

It so hai)pened, that in two of the three cases of amputation 
bleeding occurred in the shape of a general oozing from the cut 
surfaces, notwithstanding the stumps were not dressed until every 
evidence of hjemorrhage had disappeared. This oozing of blood 
occurred in both about eight or ten hours after the operation- 
The sutiues were immediately cut, the stumps opened, and alter 



CLINICAL MEMOEAXDA. -SUEGICAL. 



21 



the clots of blood were carefully removed, pledgets of lint, tlio 
roughly wet in a saturated solution of ferric alum, were freely 
applied to the bleeding surface. Ko difficulty was experienced in 
arresting the haemorrhage, and it was considered that the styptic, 
besides doing this service, exerted a very material influence 
upon the subsequent healing i)rocess by its beneficial action on 
the tissues. In one of these cases, that peculiar gasterrlioea which 
so frequently occurs after capital operations and the free use of 
chloroform, took place with a considerable degree of violence. 
Stimulants, opiates and the ordinary anti-emetic medicines were 
freely administered during the night, but as has always been ob- 
served to be the case, they proved to be worse than useless. 
When seen at the regular morning visit, he could retain nothing 
on his stomach, incessantly vomiting large quantities of vitiated 
secretion ) his pulse was feeble and rapid, and his countenance 
was most anxious and depressed. Without delay he was ordered 
eight grains of calomel, to be given in grain doses every fifteen 
or t^venty minutes. He had not taken the sixth grain when 
the vomiting ceased, and with this occurred the most remarkable 
change for the better in every other respect. Small doses of sulr 
phate of magnesia were given every hour until the bowels were 
gently moved, and this was all. He took light nourishment 
during the night, and in the morning was found partaking of an 
ample breakfast with good relish. The inestimable benefit of 
calomel, given in the small doses above indicated, in such condi- 
tions, which are far from being of seldom occurrence, cannot be 
too much extolled. In all operations where antesthsia was neces- 
sary chloroform was used — ether was never resorted to. The ad- 
ministration of the chloroform was always preceded by a stiff 
toddy of either brandy or whisky, or, as inentioned before, an 
enema of carbonate of ammonia, it being considered that it did 
away with some of the risks, and that the patient went under its 
influence more kindly. It was also made an object to bring the 
X>atient as rapidly as i)ossible under its influence, rather than 
allow him to take it sloAvly and in small doses. It was considered 
that by so doing the operator was not only spared many annoy- 
ances, but the patients escaped the bad effects which follow its 
gradual administration, while no additional danger was entailed. 



22 



CLINICAL MEMORANDA.— SUP.GICAL. 



Although it was used many times each month, no disagi'eeable 
results occurred. 

Two cases of tetanus were treated, both traumatic, resulting 
one from wound of the head, the other of the face. The symp- 
toms of tetanus manifested themselves in one case in one week, 
in the other, three weeks after the receipt of the injury. The 
disease was looked upon as one having a certain defined course 
to run, and no active treatment was attemi^ted. The patients 
were placed quietly in a bed, i^rotected from the light by thick 
curtains, and every possible care taken to preserve them from all 
soiu'ces of distiu'bance. When approached, it was done most 
gently, in such a way as not to startle them. Opium, in the form 
of hJaclc drop, combined with camx^hor, was administered in such 
quantities as to keep them moderately under its influence, and 
milk punch, beef-tea, eggs, etc., were given without stint. In 
neither case Avere the jaws so closely locked as to interfere with 
the administration of the medicine and food by the mouth. Had it 
been so, or had the act of swallowing tended to bring on spasms, 
the rectum would have been employed. The bowels, when inac- 
tive, were moved either by a gently stimulating enema or by the 
mildest laxatives. Both cases recovered under this simple man- 
agement — one in three, the other in five weeks. 

Indolent ulcers of the leg, of long standing, were treated as a 
rule, by strapping and bandaging, the ulcer having been first 
properly stimulated in the ordinary way. The chloride of zinc, 
ten grains to the ounce of water, was a favorite stimulant in 
these cases. A due amount of rest was required, and attention 
paid to the general health. To prevent that excoriation of the 
surrounding skin, which so frequently accompaides the use of the 
adhesive plaster, great advantage was found in the washing of 
the skin before each application, with a solution of nitrate of lead, 
twenty or thirty grains to the ounce of water. After a sufficient 
amount of action had been obtained by the use of such strong- 
stimulants as the chloride of zinc just mentioned, preference was 
given to the sulphate of copper, two grains of the salt to the 
ounce of water — never any stronger. Many cases occurred of 
ulcerated legs, beginning by the formation of small blisters, which 
after breaking, left ulcers more or less superficial. These ulcers 



CLINICAL MEMOPvANDA.-StJPwGiCAL. 



23 



would frequently lieal of themselveSj but only to break out again 
in a short while. In sucli cases nothing seemed to produce a 
more rapid and permanent cure than the solution of twenty grains 
of nitrate of lead to the ounce of water, with which the limb was 
to be thoroughly washed, morning and evening. 

In a large i)roportion of the irritable ulcers, more especially 
those which assumed the serpiginous form, healing on one side 
while seeming to eat their way on the other, and producing a sen- 
sation as though some corroding substance was at work, the 
greatest possible advantage was derived from the application of 
what is generally called Magendie's qesicating ointment. The for- 
mula by which it is prepared is as follows : Ten grains of metallic 
iodine, thirty grains of calomel, well rubbed up together, and one 
ounce of cerate added. The salve being spread lightly upon a 
piece of soft linen, is laid over the sore, and allowed to remain for 
two or three hours. At first it produces some degree of pain, but 
in a short while it subsides, and with it the torture to which the 
sufferer has been subjected night and day. After this application, 
the ulcers, as a rule, were completely changed in character, and 
with the ordinary simple treatment healed without difficulty. 
Sometimes two, three, and even four applications were required. 
In one case of exceedingly irritable ulcer, Avhich resisted every 
treatment that could be devised, both local and constitutional, 
Cayenne jyepiwr^ imre^ was freely sprinkled into it, and with the 
best results; in a few hours i^erfect relief was obtained. The ap- 
plication of the pepper only produced a sense of heat — not 
amounting to positive pain. The ulcer was not of that character 
to which the pepper had previously been found to be peculiarly 
applicable, but every other means having failed to give any relief 
whatever, it was resorted to as a forlorn hope, and its good re- 
sults in relieving the severe, agonizing pain, and changing so ma- 
terially for the better the character of the ulcer, entitles it to the 
most favorable consideration of the profession. Unguents, as a 
general rule, were not much used. If it was deemed expedient 
to use a soothing, and at the same time gently astringent salve, 
preference was given to the oxide of zinc ointment. If a gentle 
stimulating effect was desirable, the resin ointment, generally 
diluted with equal jiarts of simple cerate, was used. The only 



24 CLIiTlCAL MEMORANDA.— SURGICAL. 

form of cutaneous disease treated was eczema. Locally mild ap- 
plications, calculated to relieve the burning and itcliing, were 
used ; such as weak alkaline washes, with small quantities of 
morphia, the oxide of zinc ointment, etc. Constitutionally, such 
tonics as were calculated to establish vigorous health, with mi- 
nute doses of arsenic and iodine, were used. 2sot more than an 
eight to a sixteenth of a grain of iodine, with three or four drops 
of Fowler's arsenical solution, were used twice a day j frequently 
less quantities were administered, and the medicine continued 
for some length of time. 



Aet. YUl.^Surgical Memoranda : By Prof. T. G. EiCHARDSorf, 
M. D. 

1. Gunsliot ^Yo^{nd of the ]\Iemhranous Urethra Uesidting in Com- 
2)lete Occlusion J of Five Tears duration. Perineal Section ; Cure. 

Mr. F. E., of the C. S. A., was wounded at the siege of Yicksburg, 
in the spring of 1863, by a fragment of shell, which entered the 
anus obliquely from behind, slightly notching the sphincter upon 
one side and burying itself deep in the perineum. The foreign 
body having been immediately removed, the first effort to empty 
the bladder showed that either the neck of this organ or the 
urethra had been divided, as the whole of the urine escaped 
through the wound. But little constitutional disturbance ensued, 
and as no catheter was used the urine continued to be passed 
through the artificial opening into the rectum, and thence, by the 
same effort out at the anus. The wound in the mean time 
granulated and contracted, leaving a small fistulous opening com- 
niu:acating Avith the lower end of the bowel. 

The patient was brought to the cit^' and placed in my ward by 
my Iriend i)r. J. E. Wright, of Columbia, La., who informed me 
that notwithstanding repeated and careful examinations, he could 
not discover tlie outlet of the sinus, on account of its very 
small size and the corrugated condition of the mucous membrane 
of the rectum ; although it was quite evident to him that it was 
not more than three or four lines within the verge of the anus. 



CLIZS'^ICAL MEMORANDA —SURGICAL. 



25 



Upon introducing a catlieter, I found the point of tlie instru- 
ment could be carried a very short distance bej'ond the bulbous 
urethra, where it encountered an abrupt obstruction. The pa" I 
tient had complete control over his bladder, which he emptied by 
the anus at the usual intervals, not a drop of urine having i:)assed 
the meatus since the time of the accident. He had also, occa- 
sionally, seminal emissions which followed the same course. Ex- 
ternally, there was not the slightest evidence of wound of the 
perineum. 

The facts just stated ; namely, the perfect control of the sphinc- 
ter of the bladder, the healthy condition of the seminal function, 
and the ejection of the spermatic fluid through the fistula, and 
the ready penetration of the catheter a little way beyond the 
bulb, established conclusively the situation of the obstruction in 
the membranous urethra ; and the inability from the outset to 
X)ass the smallest portion of urine along the natural way led to 
the inference that the canal had been entirely sev ered. 

To re-establish the natural passage, two procedures suggested 
themselves. 1st. To divide the obstructing cicatrice from within 
by means of a lancet shaped urethrotome ; and, 2d. To i^erform 
the perineal s3ction and heal the parts over a catheter. The 
former being considered somewhat hazardous, the latter was 
adopted. The operation was performed in the presence of the 
Medical Class of the University, and a minute account of it is 
not necessary here. Suffice it to say, that with the fore- 
finger of the left hand in the rectum pressing upon the apex of 
the prostate gland, and a large sized staff held in the urethra by 
an assistant firmly against the obstruction, an incision was made 
in the middle line of the perineum directly down to the point of 
the staff, and thence carried backward toward the end of the 
finger. The urethra behind the cicatrix having become consid- 
erably dilated in consequence of the repeated pressure to which 
it had been so long subjected by the efforts of the bladder, was 
reached by the knife without the slightest difficulty, and the staff 
pushed on into the bladder. A silver catheter was then substi- 
tuted for the staff, and allowed to remain in place two or three 
days, when it was withdrawn, on account of the inflammation 
which it occasioned in the spongy urethra. An abscess in the 

4 



26 CLINICAL MEMORANDA.— STJEGICAL. 

latter situatiou followed, aud in due time was opened, and in the 
mean time a female catheter was inserted through the i^erineal 
wound into the bladder, and maintained in position by means 
of proper fastenings. As soon as the condition of the parts 
would admit of it, the latter was withdrawn, and the male cathe- 
ter introduced, by the natural passage, at regular intervals. 

Having entire confidence in the skill and good judgment of Dr. 
Wright, and feeling well assured that the desired result would 
be secured, I now permitted the patient, after two weeks' sojourn 
in the hospital, to return home, with directions to continue the 
use of the catheter, at gradually increasing intervals, for several 
weeks or months. Since then I have heard from Dr. Wright that 
the fistula resulting from the abscess and the wound of the peri- 
neum have both entirely closed, and the natural functions of the 
urethra been fully restored. 

2. Compound Fracture of the Lower Jaw^ treated tclth Beau\s 
Interdental Splint. 

Mary E., a stout Irishwoman, applied as an out-door patient at 
hospital, Marcli 1, for injuries about the face, produced by falling 
head foremost down stairs upon a brick pavement. Examination 
showed complete division of the upper lip into the left nostril, 
and oblique fracture of the inferior maxilla upon the correspond- 
ing side of the symphisis. The fragments of the broken jaw were 
jiot in api)Osition but overlapping, one of them having been evi- 
dently driven in by the fall, producing great laceration of the 
gums. With some effort the broken ends were reduced and 
brought into contact but owing to the obliquity of the line of 
fracture and the contraction of the muscles attached to the longer 
fragment, displacement recurred so soon as the hands were re- 
moved. Several and various attempts to keep the parts in proper 
position having failed, it was determined to stitch the wound in 
the upper lip, and after this was healed to have an interdental 
splint applied to the fractured bone, the parts being in the mean 
time gently supported by a compress beneath the chin, confined 
by a bandage over the head. The lip having completely united 
in the course of four of five days, the patient was taken to Dr. J. 
E. Kells, dentist, who took the necessary casts and constructed 



OLmiCAL MEMORANDA.— SUKGiCAL. 



21 



upon tbem an interdental splint of vulcanized rubber. By this 
means the fragments were brought into perfect apposition^ and so 
maintained for three or four weeks, at the end of which time com- 
l}lete union had taken place. 

The interdental splint, it may not be generally known, was in- 
vented by Dr. J. B. Bean, dental surgeon in the Confederate 
States Army, and is one of the most valuable additions made to 
the surgical armamentarium during the past ten years. A de- 
tailed account of its preparation may be found in the ^sTew Or- 
leans Medical and Surgical Journal for November, 1866, by Dr. 
Warren Stone, Jr. I take the liberty of also stating that Dr. 
Kells will cheerfully demonstrate the process to any one who may 
call upon him. 

3. Cystic Tumor of the Loiver Jaw. Removal of the larger Part 
of the Body of the Bone. 

J. F., tet. 18, from Batesville, Miss., entered Prof. Stone's wards 
in the Charity Hospital, December 7, 1867, for tumor of the lower 
jaw. The disease was ascribed to a blow received upon the chin 
two years previously, since which time the bone had been steadily 
enlarging. Upon examination by Prof. Stone and myself, the 
enlargement was found to involve both the alveolar and basilar 
divisions of the bone, from the sj^mphisis to with hi a short dis- 
tance of the ramus upon the right, and to the first large molar 
tooth upon the left side. The tumor thus formed did not exceed 
the size of a imllet's egg, but projected almost altogether towards 
the cavity of the mouth, where it interfered ver^^ uncomfortably 
with mastication and the movements of the tongue. It had never 
been the seat of any considerable pain, and there was no evidence 
whatever of contamination of the cervical lymphatic glands or of 
any constitutional cachexy. Under firm pressure it was ascer- 
tained to consist of a thin shell of bone enclosing a semi-solid 
elastic tissue. 

Taking thus into consideration the situation of the growth, its 
painless character, its comx)aratively slow increase, its semi-fluid 
consistence, the absence of any local or constitutional contamina- 
tion, and its indisposition to ulcerate, the disease was unhesitat- 
ingly pronounced cystic tumor of the bone, most probably of the 



28 



CLINICAL MEMOEANDA.— SURGICAL. 



myeloid variety. EemovrJ by tlie knife was therefore advised, 
with the assurance that a return would not be likely to occur, as 
such tumors seem to be generally benign. 

By the request of Prof. Stone, I performed the operation, in 
the presence of the medical class of the University, with the 
assistance of Dr. Warren Stone, Jr., and others, on the 9th of 
December. The method jmrsued, after placing the patient under 
the influence of chloroform, consisted in dividing the skin hj a 
single curved incision along the base of the jaw, extending nearly 
to the ramus on each side ; dissecting back the soft parts in front 
and below ^ and then dividing the body of the bone, by means of 
a small saw, a short distance beyond the limits of the enlarge- 
ment. This having been done, and a ligature i^assed through the 
tongue and confided to an assistant to prevent retraction of the 
organ and consequent suffocation, fii-m traction was made upon 
the mass at one end, and its separation rapidly effected by divid- 
ing the mylo-hyoid, genio-hyoid and genio glossal muscles close 
to their honj attachments. 

The operation was accompanied and followed by a frightful 
haemorrhage, the blood welling up from numberless vessels too 
small to be secured hj ligatures ; but by the free use of iron alum 
and filling the gaping wound with broken ice the flow was gradu- 
ally arrested, but not until the patient was apparently almost ex- 
sanguineous. It was now also found that one of the sawn ends of 
the bone presented an unhealthy appearance, and the further re- » 
moval of half an iuch became necessary j but this was readily 
effected by the use of cutting forcei)s. After reaction had been 
established by means of frictions, hot bricks and stimulants, the 
edges of the wound were brought together with twisted sutures, 
and the point of the tongue confined outside of the mouth by at- 
taching the ligature to a strip of adhesive plaster i^laced upon the 
chest. This latter precaution was absolutely necessary, for it was 
found by experiment that as soon as the traction was relaxed the 
organ was drawn back into the throat and threatened suffocation. 
15y careful attention upon the part of Mr. Watkins, the student of 
the ward, the case did well, and at the end of three days, the 
jKitient being able to control his tongue, the ligature was removed. 
The sutures were removed Ui)on the fourth and fifth days, entire 



CLINICAL MEMOEAXDA.— SUEGICAL. 



29 



union having taken place^ and in twelve clays from tlie time of 
the operation the i)atient returned home. 

Examination of the tumor subsequent to its removal proved 
the correctness of the diagnosis^ for notwithstanding the close 
resemblance of the contents of the bony cyst to the brain-like sub- 
stance of medullary cancer, the microscopic elements were those 
of myeloid tumor. In farther proof of its benign nature, it may 
be stated that it is now six months since the operation, and 
there is not the slightest evidence of any disposition to a recur- 
rence, which would scarcely be the case in encephaloid. 

4. Traumatic Epilepsy treated hy .Trephining. 

Ben Smith, twelve years of age, from Opelousas, La., came 
under my care in ]March, 1868. He was struck, December, 1866, 
in the middle of the forehead by the end of a heavy rail, which 
bruised the soft parts, but did not break the skull. An abscess 
ensued at the site of the injury, which, upon being opened, con- 
tinued to discharge for two or three months. During this time 
there was no sj mptom of cerebral disturbance, but about two 
months after the closing of the abscess, a severe epileptic spasm 
occurred early in the morning, and repeated itself at night, for 
several succeeding days. The spasms then became less regular, 
but invariably retm^ned after an interval of three or four days, 
when three or four attacks would occur during a single night. 
For several months past one or more slight movements, (what 
French writers denominate petit mal.) have taken place every 
night, alternated about every thu'd or fourth night by a severe 
spasm f grand mal. J 

Upon examination, I found a slight scar indicating the situation 
of the original injury and abscess, but not the slightest depres- 
sion or roughness of the bone could be detected. The cerebral 
functions were slow and uncertain, the expression of countenance 
rather stupid, and the father informed me that the boy's memory 
was wholl}' unreliable j but otherwise tliere seemed to be no great 
change in the mental faculties. 

The patient having been abeady submitted by his attending 
physician at home to the usual courses of treatment, including the 
free use of the bromide of potassium, I concluded, as a last resort. 



so 



CLIKICAL MEMOPvAKDA.— StTRGlCAL. 



and at the earnest solicitation of tlie father, to apply the trephine, 
suspecting that there might possibly be a slight exostosis upon 
the inner aspect of the skull, or some thickening of the dura 
mater. In this opinion and conclusion I was sustained by Prof. 
Stone, to whom the case was submitted. On the 19th of March, 
in the presence of my distinguished colleague just mentioned, 
and Dr. B. H. Moss, the patient having been placed under 
the influence of chloroform, I applied the crown of a large-sized 
trephine immediately to the left of the middle line cf the fore- 
head and about an inch above the superciliary ridge. The disc 
of bone thus removed i)resented upon its inner surface no ap- 
pearance whatever of change of structure; nor did the dura mater 
seem to me to be materially altered, although Prof. Stoie ex- 
pressed the opinion that it was more opaque than normal, and 
slightly thickened. There was, however, a considerable accumula- 
tion of serum in the arachnoid sac, which, whenever the child 
screamed, formed a i)rominent swelling in the bottom of the 
wound. So tense indeed did this swelling become under these 
circumstances that the dura mater which had been barely scratched 
by the trephine, gave way during my absence about half an hour 
afterward, and upon my return, I found the serum running down 
upon the face but it was impossible even to conjecture with any 
accuracy how much had escaped. As soon as this accident occur- 
red, the j)atient, who had been screaming at the top of his voice 
ever since the effect of the chloroform had passed off, became 
suddenly calm, and never uttered another cry. The wound hav- 
ing been left open in consequence of a little haemorrhage, was 
now closed by approximating the edges of the flap with two 
Ijoints of interrupted suture, and a small tent inserted at its lower 
angle to serve as a drain for the serum and subsequent eflusion. 

The succeeding niglit three or four slight spasms were observed, 
but the patient slept well, and the next morning exinessed him- 
self as feeling quite comfortable. A grain of calomel was ordered 
to be given twice a day with a view to its constitutional effect, 
but was discontinned after three or four days, and bromide of 
l)otassium, in thirty-grain doses morning and evening, substituted. 
Since the flrst night, now more than two months ago, no spasm has 



C LIXTC AL ME MORANDA .— SURGI C AL. 



81 



taken place but it is proper to ,adcl that the tent in the wound 
is still usedj and the patient continues to take the bromide of 
potassium. 

In reporting* this case I am fully aware that sufficient time has 
not elaT)sed to test the pernianency of the relief, but as there has 
been a marked improvement in the mental faculties, evinced 
by the brightening of the countenance, increasing cheerfulness, 
and vivacity, I am encouraged to hope that the favorable change 
may prOve permanent. The further history of the case, bo what 
it may, shall be rejwrted in the next annual publication, if not 
before. 



Art. lX.-^Medical Memoranda : By S. M. BE]vnss, M. D., Prof. 

Theory and Practice of Medicioe, etc. 
The following tabulated list represents the gross number of cases 
treated in wards 18, 19, and 21 during the term of lectures, with 
the addition of several patients sent me from other wards or fi^om 
private practice. The nosological arrangement is according to 
the classification of Dr. Farr : 



CLASS. 



ORDER. 



1 — Zymotic Diseases 



< ^ 



114 



I. — Miasmatic Diseases- 



Intermittent fever | 48 

Remittent fever 

Typhoid fever 

Yellow fever 

Acute Dysentery 

Chronic Dysentery 

Acute Diarrhcea 

Chronic Diarrhcea 

Epidemic Cholera 

Erysipelas 



21 
]| 

lol 

8! 

^1 



131 97 

i 48 
2 



Total 101 13 



II. — Enthetic Diseases — 

Gonorrhceal Rheumatism 1 

Syphilitic affections \ 5 



lOi 
1| 
/ 1 
o\ 
41 



851 



Total. 



6 



V 



32 



CLINICAL MEMORANDA.— SUEGICAL. 



CLASS. 



ORDEE 



Zymotic Diseases 
Continued. 



III. — Dietetic Diaeases- 

Alcoholism 

Mercurialism ...... 



II. — Constitutional 
Diseases. 



III. — Local 

EASES. 



Dis- 



Total. 



tV. — Parasitic Diseases- 
Scabies 



I. — Diathetic Diseases — 
Acute Rheumatism .. 
Chronic Rheumatism. 
Anemia 



Total. 



II. 



-Tuberculous Diseases — 
Pulmonary Tuberculosin 
Scrofula 



Total. 



-Nervous Syster/i — 

Hemiplegia 

Neuralgia 

Delirium Tremens., 

Chorea 

Traumatic Tetanus 
Epilepsy 



Total. 



II. — Circulatory System — 

Valvular Disease of Heart. 
Thrombosis 



Total. 



Ill — Respiratory System- 

Pneumonia 

Acute Bronchitis 

Chronic Bronchitis .. 

Laryngitis 

Acute Plouritis 

Chronic Plouritis 

->^(Edoma of Glottis.... 
f (Edema of Lungs.... 

Asthma 

Emphysema 



Total. 



3.^ 



28 



13 



13 
2 



14 



• Died of Pneumonia. f Died of Brighl's Disease. 



CLINICAL MEMORAKDA —MEDICAL. 



CLASS. 



Local Diseases 
Continued. 



ORDEIl. 



I V. — Digestive System — 

Dyspepsia 

Gastro-Duodenitis (catarrhal) 

Jaundice 

Hepatitis 

Tonsillitis 

Ascites 



Total 



V. — Urinay-y System. — 

Albuminuria 

Diuresis 



Total 



IV. — Development- 
al Dlseases. 



VI. — Generative System, — 
Seminal Losses 



VII. — Locomotive System — 
Synovitis 



VIII — Integumentary System- 
Eczema 



IV. — Diseases of Nutrition — 

Lardaceous Liver and Spleen. 



Grand Total 



10 



201 



o 

ft t 



26 141 



1 

22 



The Zymotic diseases exhibited their usual importance, both as 
respects the high rank of the figures by which they are repre- 
sented in the mortality list, and as affording interesting examples 
for clinical study. 

The Periodic Fevers included but one case so irregular, or ma- 
lignant, as to justify its classification among the ''pernicious" 
forms. I think this case was properly diagnosed as " malarial 
coma" by Mr., now Dr., Kelly. The patient had two paroxysms, 
occurring upon alternate days, marked by unconsciousness, heavy 
breathing and struggling pulse. Kapidly induced cinchonism 
X^revented a third return, aiid the patient left the hospital on the 
second day after admission. 

In the aggregate, the cases of malarial diseases admitted to 
hospital were attended, in more than the ordinary ])roportion of 
instances, with enlargement of spleen, auoemia and disposition to 



34 



CLINICAL MEMORANDA.— MEDICAL. 



recur. The promiuency of these clinical features rendered tlie 
prescription of iron, arsenic and stryclinia frequently necessary. 
Elforts Avere made to desiguate the cases for which each of the 
remedies above enumerated was considered specially appropriate. 
Ohalybeates were obviously indicated to restore impoverished 
blood. Arsenic was considered specially adapted to cases marked 
by periodic neuralgias ; but was also prescribed as antiperiodic 
where the return of paroxysms was not i^revented by quinine. 
Strychnia was likewise sometimes given as an antiperiodic j but 
more often Avith a view to its influence as a direct and powerful 
nerve tonic. It was therefore given preferably in those cases iu 
which the recurrence of the paroxysms seemed ascribable to im- 
pressions stamped by force of habit, or otherwise, upon the ner- 
vous system. In no other manner does it seem reasonable to 
account for the periodicity, marking, in after life, the diseases of 
persons who have for a considerable time been the subjects of 
malarial influences. 

It may be profitable to those who failed to coi)y the ])rescrip- 
tions from the ward-books, to mention some of the formuhie em- 
ployed in the treatment of periodic diseases and their sequela3. 
When speedy cinchonism was sought, the house solution of qui- 
nine, containing five grains quinine and ten drops tincture of 
opium to each 31, was exhibited in from 3i to 3ii doses until this 
end was accomplished. Iron was given in combination with 
quinine in the following forms : I>. Citrate of iron and quinine, 
3ii5 infusion gentian, ^iv. M. S. Tablespoonful thrice daily. 
R. Ammonio-sulphate iron ; sulphate quinine aa. 3ii ; aromatic 
tinct. sulph acid, 3i to 3ii ; water fii. M. S. Teaspoonful or 
dessert-spoonful thrice daily, or every fourth hour. (Prof. Mallet.) 
IjL. Precip. carb. iron, sulph. quinine aa. 3ii ; pulv. rhubarb 3i. 
Divide in twelve powders. S. One thrice daily. I)L. Sulph. 
quiiuue, suli)li. iron aa. 3ss5 extract nux vomica, 3i 5 xmlv. aloes, 
grs. XV. M. ]>ivide in twenty pills. S. One thrice daily. 
Arsenic was given in Fowler's solution, gtt. vii to xii tbrice daily. 
Strychnia in ]\Lirshall Hall's solution. J>. Strychnia gr. i ; dilute 
alcohol 3i j acetic acid gtt. xv ; water, 3vii. M. S. Twenty to 
thirty drops tliricc daily. 

The lre(|nency of blood deteriorations, as a i)roniinent charac- 



CLINICAL MEMORANDA 



—MEDICAL. 



.35 



tcristic of tlie periodic diseases of 18G7, may account for the many 
cases of malarial liematuria reported in different x)arts of the 
South. Letters have reached me, and students have applied, 
asking opinions in reference to the i)athology and treatment of 
this alarming manifestation of disease. It has seemed to me that 
its cause must he found in one or more of three i)athological 
states. First, alterations of the blood itself, favoring its extra- 
vasation ; second, physical obstruction from stasis or congestion; 
third, imi)aired nutrition of the capillary walls, rendering their 
rupture abnormally easy. The frequent occurrence of capillary 
engorgements and areolar inliltration proves that the blood is 
liable, under malarial influences, to undergo alterations affecting 
its properties as a circulatory and osmotic fluid. Congestions 
are a part of the phenomena of every paroxysm of malarial fever. 
The more easy rupture of capillary walls in cases marked hj con- 
siderable or long existing imx^airment of nutritive processes, is 
not only an inferential event, but is proved by the readiness of 
sanguineous extravasation after bruises or the application of dry 
cups. The best teachings of pathology justify the conclusion that 
capillary rupture is essential to the occurrence of hismorrhage, 
therefore the effects of impaired nutrition upon the renal blood 
vessels, in weakening their capability of resisting pressure, must 
prove the most imi^ortant factor in the production of hematuria. 
We therefore expect bloody urine to complicate those cases of 
malaria in which the processes of nutrition and tissue-change 
suffer greatest damage, whether that derangement is the result 
of long existing cachexy, or a perversion of fluids and solids, oc- 
curring more rapidly, as in poisoning from phosphorus or in 
many cases of yellow fever. We must await the accumulation of 
more facts before venturing upon a more authoritative explana- 
tion of the iiathology of malarial hematuria, or of the cause of the 
greater frequency of the symj^tom in connection with some epi- 
demics than with others. 

The first appearance of the blood is generally during, or imme- 
diately subsequent to a paroxysm. Sometimes its presence in 
the urine is limited to a given stage of the paroxysm ; in other 
cases it becomes persistent for a number of days, or until death. 

Dr. Brinton explains the admitted liability of renal htemor- 



36 



CLI^^ICAL ME310EANDA.— MEDICAL. 



rliage to return, or become elirouic, by referriDg the fact to the 
derangements and obstructions in the circulation of the kidney, 
occasioned by the extravasation itself. The haemorrhage is rarely 
in sufficient quantity to imperil life hy loss of blood, however 
seriously it may affect prognosis by pointing to morbid states, 
whose significance the exi)erienced physician at once apprehends. 

The treatment shoukl vary accordingly, as the medical attend- 
ant estimates the pathological state underlying and causing the 
haematuria. As in all cases of pernicious, or irregular malarial 
attacks, the indication urgent above all others would be the pro- 
duction of cinchonism at the earliest i)racticable moment. The 
remedies most likely to arrest the haematuria, if it proceeded from 
increased pressure, either distal or proximal, would be such as 
relieved the congestion, whether portal or renal j and such as 
subdued the heart's action, if the i)ressure which ruptured the 
capillaries was from excessive arterial force. Cold to the lumbar 
region, or, according to Mackintosh, cold water enemata would 
be useful adjuvants. Haematuria from depraved blood, or the 
weakened vascular walls of innutrition, would require remedies 
addressed to these conditions. 

The astringent preparations of iron j vegetable bitters and 
mineral acids in combination j tannic acidj ergot, and opium 
would constitute judicious prescriptions, accordingly as an ana- 
leptic effect or an influence ui^on the capillary vascular system 
was the object sought to be obtained. 

The case of typhoid fever was a strongly illastrative example of 
that disease, being characterized by the usual intestinal sym^)- 
toiES and the rose erui^tio::. It progressed to a favorable issue 
under the observation of Prof. Chaille. The treatment he insti- 
tuted was the mineral acids, and careful attention to regimen. 

A large x^lilegmonous abscess occurred as a sequel in this case, 
and was opened, allowing a free discharge of pus. Two ethers 
were threatened, but disappeared under the local application of 
tinct. of iodine persistently made. Under my observation, success 
in the dispersion of threatened abscesses occurring as sequelae of 
blood diseases is the exception rather than the rule, and such is 
the previously announced experience of my colleague. 

Tlie following notes, very greatly condensed, are only intended 



CLINICAL MEMOEANDA. 



—MEDICAL. 



37 



to i)rcseut sucli a summaiy of the leading symptoms and points 
of treatment of the yellow fever cases, as to enable those Avho 
witnessed them to individualize each one. 

William Davies, aged 32, in Kew Orleans one week, admitted 
to bed 273 November Gth. Taken sick afternoon of 5th; took 
quinine 3i, had warm pediluvium immediately, and castor oil 
|ss. ^OY. 7th, apyrexia ; irritability of stomach and tenderness 
upon pressure. Keutral mixture, .^ss ; morphia, one twenty-fourth 
part of a grain ; repeat each hour until the stomach is quieted. 
Sinapism to epigastrium. 8th. Continue treatment ; very small 
portions of iced milk permitted. 9lh. Bi-carb. soda, gr. iii; cherry 
laurel water, 5i ; morphia l-2J:th part of a grain ; orange flower 
water, fi. every two to four hours. 10th. Patient improved. 
Beef-tea and chicken water : wine of bark. Discharged Xovem- 
ber 14th. 

John S. Curtis, aged 25, in Xew Orleans ten daj s, admitted to 
bed 284 i^^ovember 13th ; taken sick on previous day. First pre- 
scriptions as in preceding case; iced drinks and cold to head. 
On 14th and 15th took 3ii liq. acet. amm. ; spts. nitre, 3ss ; orange- 
flower water, 3i. M. S. Every three hours. Small portions of 
iced milk. On 17th, pale ale, beef and chicken essence. Dis- 
charged November 23d. 

Pat. Couley, aged 22, in New Orleans ten days, admitted to 
bed 285 November 24th. Taken on 21st with a chill, followed by 
fever. Countenance dusky and turgid ; eyes injected, gums red 
and swollen. Pulse obliterated by moderate pressure ; urine 
charged Avith albumen and reduced in quantity. He was ordered 
spts. nitre 3ss in effervescing citrate potash every second hour, 
and efforts were made to sustain him by administering beef essence 
and brandy by mouth and rectum. He died on the 26th. Deli- 
rium, coma and complete suspension of urine existed for over 
twelve hours prior to decease. No post-mortem. 

AY. Dietrich, aged 2G, arrived in New Orleans in October; ad- 
mitted to hosi)ital November 4th, to be treated for malarial fever 
and diarrhoea ; had well defined attack of yellow fever J anuar^^ 
4th, took castor oil 3ss, followed by quinine 3i. Febrile parox- 
ysms lasted over seventy hours ; urine albuminous and tinged 
with bile pigments ; convalescence tedious and complicated by 
bloody furuncles. Treatment — Nutritious food, stimulants, iron, 
quinine and iodide of potassium. Discharged February 9th. 

George Fitch, admitted to bed 289 October 10, on the subse- 
quent day to his attack. He was ordered a warm mustard foot- 
bath, with 3iii Haustus quinia of the house (equal to 15 grs). 
On the 17th, marked tenderness over the epigastrium and nausea. 
Ordered bi carb, soda and cherry-laurel water. Black vomit oc- 
curred during the night and persisted throughout the 18th. 
Patient was permitted pellets of ice and sustained •by enemata of 
beef essence and brandy. Convalescence was slow aiul attended 



CLI^'ICAL A1EM0HA^■1) A. —MEDICAL 



by numerous furuueles. especially abuudanr about the ueek and 
Lauds. Treatment during convalescence — iron and mineral 
acids, tlie latter given in cold infusion of wild clierry bark. Dis- 
charged December 1. 

Michael Collins, admitted to bed DOO October 23. the second 
day after seizure. Took ten grs. quinia each day for three days. 
Xo vomiting. Supported during calm stage with milk punch and 
beef essence. Convalescence tedious and complicated with paro- 
tid abscess. Treatment during convalescence — niur, tiiict. iron 
and chlorate potass. Discharged Xov. 20th. 

John Smith, admitted to bed 301 Xov. IJrili. thirty hours after 
seizure. Ordered castor oil 3SS and warm mustard pediluvium, 
to be followed by liq. annnon. acet. 5SS, every three hotirs. Secre- 
tion of urine abundaiit. Xo albumen. Complexion of patient 
<liugy yellow, and niarlcs of pressure upon surface slowly disap- 
pearing: eyeii injected and gums swollen : skin moist. On the 
17th the color of the patient had 1 H'CiMne a brighter yellow. Urine 
scanty and containing albumen. ]\[ind wandering. Died on 19th. 
without black vomit or other hipmorrhage. 

John Beatty. admitted to bed 310 Dec. 1th. Gut mustard foot- 
bath and fifteen grains quinine. Had copiotis ejections of black 
vomit. -^Ith retention of urine. Sustained by nutritious and stim- 
ulating enemata. Convalescence attended with insomnia and 
distressing paralysis agitans. Gave bromide potassium ~ss. tinct. 
lupiiliu, 3i, thrice daily. Patient in hospital under treatment 
for partial paralysis of traumatir origin. 

John Kind, admitted to bed 303 October 13th. second day of 
attack. Case progressed towards convalescence ver^' satisfac- 
torily, but patient went out w ithout sanction on 20th. and was 
speedily brought back to suffer his -elf-intiieted i^enalty of in- 
terrupted couA'alescence. He remained under treatment until 
January 11th, for diarrhcea, vomiting and violent paroxysms of 
lever, terminating in jirofuse sweats. The treatment consisted of 
quinine, chalybeates. mineral acids in bitter infusions, and a care- 
ful regulation of his diet. 

That the pathological phenomena uf fellow fever take their 
point of departure iu perverted chemistiy, is a proposition now 
generally admitted. But in what these errors of the chemistry of 
the economy essentially consist, will not be explicable until the 
nature and mode of action of the specific poison are unfolded. 
One of the earliest and most prominent of its effects, seems to be 
a remarkable disqualification of the blood for the discharge of its 
great functions as a dispenser of nutritious material, possibly of 
oxygen. AVe find as an almost universal resultant of this intlu- 
ence, that the dynamical forces of the economy are reduced to the 
lowest minimum C(nnpatible with the sui)]^ort of life. Tt i> be- 



CLINICAL MEMORANDA. 



—MEDICAL. 



80 



cause of this condition — tliis silent but dubious equipoise between 
the vital powers and an unknown but potent toxic agent — that a 
most sagacious observer remarked, that the successful treatment 
of yellow fever depended more upon the observance of little things 
than that of any other disease.'^ 

The case of Patrick Conley was pointed to as illustrating the 
truth of this remark. Had he received the requisite attention 
earlier, there is no good reason for supposing that the case would 
not have resulted in recovery. The patient was a man of unusual 
physical development and vigor, but it is against all medical 
philosophy and all ^our knowledge of the action of the " vis 
medicatrix natura3," to believe that patients are more liable to 
die of yellow fever because they are more healthy at the period 
of attack. Persons in the full tide of health, and especially those 
whose occupations or imprudent habits devolve upon them an in- 
creased liability to derangements of function, are more apt to be 
guilty of indiscretions which may invite attacks of this epidemic, 
and which render them more hazardous when they do occur. 
Another fact which, in all probability, is fully as operative in in- 
creasing the mortality among this class of persons is, that they 
are more likely to neglect the first stage of the disease, during 
which the injury it inflicts is almost Avholly wrought. It is, there- 
fore, not because these persons are in strong health that they 
fall victims to yellow fever, but because derangement of one or 
another function or organ so complicates some state in the morbid 
process as to give a fatal conclusion to the case. It may be true 
that certain morbific agents act with more energy in states of the 
blocd existing in plethora, or even in high health, and I shall not 
be understood to deny the common allegation that the poison of 
yellow fever belongs to this class. l>ut if this should be allowed 
to be the case, and the admission granted, that by reason of more 
rapid multiplication, or other cause, this poison obtains greater 
intensity of action in previously healthy subjects, the proposition 
is no less true, that its removal or destruction depends upon 
healthy function, and takes place with a certainty and rapidity 
proportionate to the number and importance of the functions un- 
impaired. 

It was long since held, and has recently been eloquently re- 



40 



CLII^ICAL MEMOEANDA.— MEDICAL. 



iterated by Prof. Dickson, that the action of the vis medicatrix 
naturoB is vigorous and efficient in direct proportion to the num- 
ber and importance of those functions wliose integrity remains 
unimpaired during assaults of disease — that in truth the vis 
medicatrix, viewed as an agent capable of resisting or curing dis- 
ease, is only the aggregated force of healthy functions, to the sum 
of which each normally working organ contributes, as a more or 
less important factor. In a physiological aspect, different func- 
tions possess an imi)ortance more or less fixed and absolute, while 
in pathological states the scale of im];)ortance is liable, with re- 
spect to many of them, to be shifted accordingly as the integrity 
of a particular function may be more necessary to recovery from 
a particular example of disease. These observations seem emi- 
nently applicable to yellow fever. The great indication of cure 
is conservation of function, until nature rids the system of the 
materies morbi after her own methods. The term conservation 
of function should be understood to imply normal activity, not 
excessive activity. For exaDiple, the easy production of diaphore- 
sis in yellow fever may be interiireted as an indication, that this 
is IN'ature's mode of eliminating the poison, and that therefore 
activity of this function is a paramount consideration in treating 
the disease j yet, all experienced physicians know how frequently 
errors are committed in directing efforts at cure solely to this 
point. The deluge of diaphoretic drauglits poured into the 
stomach induces fatal irritability j the profuse perspiration ex- 
hausts the patient, and, i)erhaps not the least of the evils, the 
excessive functional activity of one class of organs destroys the 
balance necessary to the general conservation of healthy func- 
tion. 

TJie propriety of exhibiting quinine as an initiatory step in the 
treatment of yellow fever is a question which has involved con- 
siderable discussion. All physicians will admit the indications 
for quinine in cases supposed to be commingled with malaria, 
and a large iuiiid)er prescribe it in congestive cases, leaving the 
question open as to tlie i^resence or absence of the malarial ele- 
ment of disease. Ihit to present the question properly, it is 
necessary to exchule these cases, and enquire whether any ad- 
A antage and wliat advantage is to be expected from its use in the 
treatment of yellow fever as an essential disease. 



CLINICAL MEMORANDA —MEDICAL. 



41 



Neither this nor any ctlier drug hitherto recommended is known 
to possess any quality antidotal to the poison of yellow fever. Yet 
there are certain pathological conditions connected with the disease 
in which the use of quinine seems productive of benefit. First, it is 
prescribed by many experienced and judicious practitioners, as cus- 
tomary initiatory treatment. It is then given in decided doses, re- 
peated at such intervals that 3i to 3i may be exhibited in 6 or 8 
hours, and is supposed to act beneficially, through its influence 
upon capillary circulation and upon diaphoresis. This latter func- 
tion is surely modified by quinine — modified not so much in being 
rendered more profuse, as in being rendered more uniform and 
persistent. The opponents of this practice, who appear to me 
more numerous than its advocates, charge to its use the produc- 
tion of gastric irritability, which is unquestionably a serious evil 
as well as a possible result from its use. They likewise bring 
against it the more questionable accusations of producing cephalic 
determinations and gastric inflammations. I have had no reason 
to be dissatisfied with my practice, which has been to give grs. x v 
to 3i, in those cases which I saw in the early hours of the febrile 
paroxysm, and in which an irritable stomach did not forbid its ex- 
hibition. If gastric irritability does exist, or there is fear of pro- 
ducing it, all the good effects of quinine can be attained -per 
rectum, and its evil results avoided. 

There is less disagreement in the profession as to the applica- 
bility of quinine to meet various indications occurring in the late 
stages of yellow fever, l^ot infrequently febrile exacerbations of a 
periodic character comx)licate the approaches to convalescence ; 
the control of quinine ovt r these is undoubted. Its utility as a 
general tonic in prolonged debility is unquestionable, and its local 
influence upon mucoas surfaces in the cases of dyspeiisia following 
in the wake of yellow fever may also be beneficial. 

The other measures of treatment enjoined in my wards, dur- 
ing the febrile paroxysm were to free the bowels of their 
contents with from §ss to si of castor oil, or if sick stom- 
ach rendered oil inadmissible, by means of enemata. In one 
case, in consequence of frequent vomiting, two doses, each con- 
taining calomel grs. V, bi carbonate soda grs. v, were given at in- 
tervals of three hours with manifest advantage. Theoretically, 



42 



CLINICAL MEMORANDA.— MEDICAL. 



the saline cathartics shoukl possess advantages over other purga- 
tives in yellow fever, because they relieve engorgements of the 
intestinal capillaries by serous effusion, but practical]}^ their want 
of uniformity of action is an insurmountable objection to their use. 
Xo efforts were made to abridge the febrile paroxysm by arterial 
sedatives. Solution of acetate ammon. or potash, or light draughts 
of acidulated drinks, aromatic infusions, warm or cold as preferred, 
or simiDly cold water, with warm i^ediluvia and tepid sponging, 
constituted the sum of treatment ordinarily addressed to the 
febrile stage. 

After the termination of the fever, the great desideratum is to 
restore the comi)osition of the blood to its healthy standard. No 
doubt this end involves both a process of addition and one of 
subtraction, but we know too little of the nature of the latter jno 
cess to attempt its formulization, consequently we direct our 
energies to the attainment of the former point of reconstruction, 
and leave the latter to be accomplished in train, by retrograde 
nutrition. The means instituted for the purpose of direct nutrition 
must be guarded by more than ordinary circumspection. The 
functions of the stomach are nearly always imperfectly i)erformed, 
either because of structural changes or from failure in the pro- 
duction of gastric secretion by reason of defective nerve supply. 
No formal rules can be laid down for the guidance of the inex- 
perienced practitioner, in respect to tlie character or amount of 
nutrition to be allowed his patient. It had better be given in 
concentrated and fluid form, so that the stomach shall not be at 
any time unduly distended by the quantity requisite to nourish 
the patient, or taxed by long in^ocesses of digestion. Alcoholic 
stimulants, and especially the effervescing fermented drinks, are 
nearly always grateful, and are sometimes positively beneficial. 

Success in treating yellow fever is closely connected with the 
attention bestowed upon the apyrectic stage. It therefore affords 
a test of the degree of medical skill brought to its management. 
The deceptive calm, which tempts the unwary physician to think 
that his professional ministrations have reached a happy conclu- 
sion, and tempts the patient to commit the fatal error of quitting 
liis bed, should never throw us off our guard or occasion a relaxa- 
tion in our attention to imtients. 



CLINICAL MEMORANDA.— MEDICAL. 



43 



Very minute closes of morpliia or some other form of opiate, 
were sometimes of great service in quieting irritable stomach in 
any stage of tlie disease. Good effects were also obtained from 
opium in the relief of another train of symptoms which not infre- 
quently complicated the calm stage. I refer to delirium and 
insomnia J no doubt referable in very many instances to exhaus- 
tion or innutrition of the centres of grey matter. It is of much 
importance, before prescribing it, to determine that the delirium or 
insomnia is not due to uraemia or other blood-poisoning. All the- 
rapeutical observation teaches that opium is not antidotal to any 
form of tox£emia, and is pernicious to most exam]3les, because of 
its immediate interference with functional activity and processes 
of elimination. 

It is more than likely that bromide of potassium will become 
serviceable in relieving these conditions, I had an opportunity to 
observe its effects as prescribed by Dr. Smythe, House Surgeon 
of Charity Hospital. It was also i)rescribed for one of the cases 
treated in mj wards. It has one unquestionable recommendation, 
— that of producing no disturbing or injurious effects, and the 
class were specially admonished that, if they limited their reme 
dies to those only which possessed this qualification, the list ap- 
plicable to the treatment of yellow fever Avould be few in number. 

The cases of acute dysentery require no particular comment. 
All recovered under the use of saline cathartics, opiates and warm 
fomentations over the abdomen. One case of chronic dysentery 
was discharged in an imi)roved condition. Post-mortem ex- 
amination of the fatal case showed extensive ulceration of the 
large intestine. 

What i)roportion of the cases of acute diarrlioea were depend- 
ent upon the epidemic influence of cholera, it is impossible to deter- 
mine. As the greatest number of the cases occurred during the 
the early i^art of the winter, when cholera existed as an epidemic, 
it is reasonable to suppose that some at least were due to its 
inflLience. All the cases resulted in recovery; the treatment 
employed being in most instances 3ss doses of the following solu- 
tion : II. bicarb. i)otas., tinct. opium, aa 3i ; pepperuiint water 
lii to be repeated every two to four hours. 

Chronic dysentery and chronic diarrhoea are among the most 



44 



CLINICAL MEMOEANDA.— MEDICAL. 



hopeless examples of disease we are called upon to treat. If the 
results of cases observed during the session were more than usu- 
ally favorable, it is probably owing to the fact that they were 
admitted to hospital in earlier conditions of the disease than 
usualj and not to any improved or more successful mode of treat- 
ment. 

More extended experience in the treatment of chronic diarrhoea 
confirms an opinion long held, that more can be accomplished in 
effecting permanent cure, by careful and judicious adaptation of 
the diet than by the exhibition of drugs. It is difficult to sepa- 
rate the various elements which enter as factors into the patholo- 
gical condition of different cases of diarrhoea, so as to accord to 
each one its due degree of influence. Excluding those cases in 
which the cause is ascribable to structural alterations of the 
mucous surface from inflammatory action of whatever grade, there 
are many instances of this disease liable, like the former class, to 
prove fatal, and yet whose pathology is but little understood. 

Some of these cases may find their proper exi)lanation in the 
existence of a state of hyi>eriiesthesia of the nerves distributed to 
the muscular coat of the intestinal walls, while others seem con- 
nected with alterations in the gland structure of the bowels, and 
death takes place from inanition, although the diarrhoea may be 
arrested. 

Many of tlie members of the class will be able to recall a case 
of diarrhoea in the person of an Irish sailor twenty-eight years of 
age admitted to bed — ,ward nineteen, on the 30th day of January. 
This case was diagnosed as depending upon the last mentioned 
cause, and the attention of the class was invoked to its course 
and post-mortem appearances. The treatment at^first consisted of 
fiv6 grains of bismuth with one eighth grain of morphia every 
four hours, until gastric and intestinal irritability was somewhat 
relieved, when the intervals Avere increased. In a day or two all 
medication was suspended, except fifteen grains perchlorate bis- 
muth twice daily and an anodyne enema or suppository, when 
tlie Irequency of the defections demanded. A great variety of 
expedients was resorted to for the purpose of secuiring the nourish- 
ment of the patient. 

The diet ordered liini consisted of boiled milk, milk punch. 



CLINICAL MEMORANDA.— MEDICAL. 



45 



milk and lime water, eggs, soups and concentrated meat essences. 
Perliaps it may be affirmed that the nse of Liebig's Eestorative 
Soup for Invalids was better adapted to liis case than any other 
one article of diet, (see fifth edition of Tanner's Practice, page 
713.) The patient was extremely irritable in temper, and could 
not be induced to take cod-liver oil. The great care bestowed 
ui)on this patient by Dr. Kelly, my ward assistant, by the faith- 
ful nurse in that w ard, and in the preparation of his food by the 
Sisters, prolonged his life for more than two months. 

Prof. Chaille made the post-mortem examination without find- 
ing any evidence of inflammation, ulceration or other structural 
lesion to account for death. 

The following table shows the name, age, date of admission, 
and death or discharge of the cases of cholera in my wards : 



Name. 



Date of Date of Date of 
dis- 
I charge. 



Bird 

Carr 

Harper. 
Morris.. 
Snyder. 



P. Harrison 1 50 



G. Burbridge 
^Y. Barbor.... 
^y. Wilson... 

AV. Tucker 

J. Cavetta .... 



Age 


admis- 
sion. 


death | 

1 


28 


Nov. 9 


Nov. 10' 


18 


u 14 


" 14, 


25 


" 20 


20' 


23 


" 28 




15 


" 28 


Dec. 1 1 


30 


Dec. 2 


: !i 




" 3 






- 17 


- 18' 


29 


Jan. 10 


1 


25 


" 18 


1 


24 


" 22 


Jan. 26 



iDec. 3. 



Eemarks. 



C. McQuadc ] 22 



Eeb. 1 



Eeb.25. 



Admitted in consecu- 
I tive fever. Diedcom- 
: atose. 

Imperfect reaction, fe- 
:tid sanguinolent stools. 
, Collapse. 



Collapse-imperfect re- 
action — sanguinolent 
stools. 

Opiates, astringents, 
careful feedino;. 



Statistics made up from groups of cholera cases, arranged with 
reference to particular modes of treatment, possess but little -pvac- 
tical value 5 I have therefore tabulated these cases, for the sole 
purpose of aiding the notes or the recollections of students in 
individualizing their observations. I had no specific or exclusive 
method of treatment to impart to them 5 but while admitting with 
Dr. Wilks, that we know of no medicine which will astringe 
cholera," I hold that all experienced physicians are able to recall 
cases which have amended in such direct obedience to the laws 
governing the action of certain medicines they have exhibited, 



46 



CLINICAL MEMORANDA.— MEDICAL. 



that they feel assured the amendment was brought about by the 
remedies in question. Much skepticism has been engendered 
in the profession in regard to the efi&cacy of cholera practice, be- 
cause of the recorded instances of high death rate under every 
variety of treatment. Even after admitting the numerical accu- 
racy of these statistics, they cease to exert such an effect when 
we take into account the great difference in the mortality rate of 
different epidemics. It may also be stated that, if the observa- 
tions of Lionel Beale become a law of cholera pathology, the ex- 
tent and gravity of the pre-existing structural change of intes- 
tinal villi will be supposed to have very much to do in determining 
the result in individual cases, as well as in producing increased 
liability to attack. The followiug extract will show, in the brief- 
est manner possible, the result of Dr. Beale's microscopical re- 
searches in regard to cholera : In almost all the cases of cholera 
I have yet examined, there is e\'idence of chronic structural 
change in the tissues of the intestines, and I think we shall be led 
to conclude that in most of the cholera victims imi)ortant morbid 
alterations have been going on for months, and in some instances 
for years, before death. In some cases it is probable that, had 
the individual escaped cholera, he must have succumbed to some 
other malady within a short period of time." These observations 
must not be understood to contravene the well admitted theorem, 
that cholera has its own specific poison, whose presence is a sine 
qua non to the existence of the disease. The pre-existing tissue- 
changes may affect the receptivity or ^^ca])ajc moybl^^* of persons 
in whom they exist, but they cannot originate cholera c'.e novo. 
These discoveries do, however, afford the most reasonable expla- 
nation of the remarkable differences in respect to individual lia- 
bihty to invasion, which we observe in all cholera epidemics, not- 
withstanding ap])arently equal degrees of exposure. This personal 
difference, as it respects recei)tivity or resistance, is sometimes 
referred to moral influences, and has been explained by supposing 
tliat mental anxiety or dread is a predisposing cause. AVe can- 
not for a moment admit that any degree or phase of i)sychical 
influence is capable of creating the sj)ecific cause of cholera. It 
is therefore reasonable to infer, that mental apprehensions, by 
depressing nerve function and vital forces, exert a much more 



* Prof, Hanghton. 



CLINICAL MEMORANDA.— MEDICAL. 



47 



important effect in determining the issue of cholera attacks tlian 
in inviting them. 

The treatment recommended for the active stages of cholera 
regarded the leading indication to be limitation of the discharges. 
All cases of diarrhoea admitted during its prevalence were treated 
with great promptitude by opiates and astringents. There is no 
proposition accepted with greater unanimity in the profession 
than the amenability of choleraic diarrhoea to medical treatment. 
This proposition cannot be invalidated by alleging that the cured 
cases were not premonitory to cholera, for too many instances 
are recorded of the prompt arrest of cholera visitations in armies 
or beneficiary institutious by establishing compulsory treatment of 
all attacks of diarrhoea. All the prescriptions made for the arrest 
of diarrhoea contained opium as the leading ingredient. The form 
most frequently followed was the tinct. of opium with bicarbonate 
of potash and peppermint water, as found on a i)revious page. 
Essence of ginger was occasionally added, and if there existed 
any tendency to cramps, chloroform was joined with the prescrip- 
tion. My experience does not teach me to believe that sulphuric 
acid possesses any specific control over choleraic discharges, but 
it is unquestionably a valuable and agreeable prescription. Some 
cases of developed cholera were treated by morphia, given in 
suitable doses and at suitable intervals, and sulphuric acid 
lemonade. The usual formula by which this was made was— R. 
Sulphuric acid (dilute), 3ii syrup ginger, ^ii j water, ^iv. Mix. 
Tablespoonful to a pint of water for a drink, or a tablespoonful 
every two hours. 

The treatment of developed cholera, dating the commencement 
of this stage from the period when the ejecta were rice-water in 
appearance, differed from that of the preliminary stage in energy 
rather than in character. Whatever theory may be entertained 
in regard to the eliminative nature of cholera stools, collapse and 
death bear too decided a relation to the amount of ejecta to jus- 
tify their encouragement as the rule of cholera practice. Although 
almost all correct observers admit that those cases of cholera 
which have recei\ ed hypermedication in the form of opium, chlo- 
roform, brandy, and every species of stimulant which can be 
gotten into the stomach, if they recover at all, are more sure to 
have troublesome symptoms during the stage of restitution j this 
fact should not be seized upon as exhibiting proof that the 



48 



CLINICAL MEMOEANDA.— MEDICAL. 



seqnehie were produced by confining cholera poison in tlie system. 
It is more than ijrobahle that simihir results would ensue with 
equal certainty upon immoderate dosing with such toxic agents, 
whenever the blood was so altered, h\ loss of its watery i)ortions, 
as to clog those processes by which it rids itself of useless or 
hurtful material. 

The snpervention of collapse was generally an indication for 
suspending the use of medicines. Collapse arrests the choleraic 
process of serous eftusion with the same certainty that syncope 
l)uts a stop to true hsemorrhage. The treatment of this cozidition 
was therefore confined to efforts to nourish and preserve warmth. 
Yeuous injection was not practiced, although held to be a justifi- 
able measure under X)roper circumstances. The ingredients com- 
posing B. W. Eichardson's artificial serum, or blood food," toge- 
ther with an instrument for its injection, were prepared by Prof. 
Mallet, so that it might be used without delay, but no case suit- 
able to its nse occurred after this period. Subcutaneous injec- 
tions were not resorted to, because not found necessary. 

The patient admitted during consecutive fever was a fine-looking 
lad, fifteen j'ears of age. The history obtained of his case was 
imperfect, but led to the supposition that he had been partially, 
yet not fully, collapsed. When admitted he was somnolent, but 
coherent when aroused ; the eyes were injected, pupils thought 
to be somewhat contracted, but not especially abnormal ; carotids 
pulsating strongly ; tongue red and dry ; skin dry ; urine passed 
in bed, but apparently sufficient in quantity. The patient stated 
that incontinence of urine during sleep had always been an un- 
controllable habit. On the day alter admission the patient was 
less somnolent and seemed better, but the apparent amendment 
existed for a short time only. On the third day after admission 
he became comatose, and died without convulsions on the fourth 
day of treatment, or sixth, dating from i)eriod of first attack. 
The treatment consisted in diuretics, diluent drinks, sponging 
the surface with warm water, cold to the head, and careful in- 
structions as to nourishment. We are not warranted in assuming 
that death in this case was due to urtemic intoxication. The 
secretion of urine was not suspended or greatly diminished until 
shortly previous to death. It was found impossible to procure 
any specimen for the purpose of determining whether or not it 
was albuminous. The i^rominent symptoms are those described 



CLINICAL MEMOPvA^*DA — MEDICAL. 



49 



by Worms as referable to turgescence of cerebral capillaries from 
thickened blood — essentially congestive apoplexy. 

The cases of erysipelas were intercurrent, both occurring in the 
same ward and within a few days of each other j one in the person 
of a patient under treatment for anaemia, the other being under 
treatment for pulmonary i)hthisis. They ran a favorable course, 
having been carefully watched over by my ward assistant, Dr. 
McXeil. The treatment consisted of mur. tinct. iron and chlorate 
potass., with lead lotions topically. 

The case which was diagnosed as " gonorrhoeal rheumatism," 

was a sailor, aged about 40, occupying bed , in ward . 

He had suffered five previous attacks of gonorrhoea, in each in- 
stance accompanied by a rheumatic affection of one or the other 
lower extremity. In the present attack the ankle and knee joints 
of the same leg were the seats of the local inflammation. It was 
therefore not strictly mono-articular, which some observers make 
an essential point of diagnosis, but it is equally true that even in 
this subject there was not now, nor had there ever been, that 
tendency to migratory invasion of a number of joints usual in 
true rheumatism. Xo tendency was shown to imi)licate other 
structures than the articular in the morbid process. It was 
taught that the pathology of this case depended upon the influ- 
ence exerted on the blood by certain unknown products of the 
urethral inflammation. Whether this influence was merely a 
derangement or alteration of blood elements due to its passage 
through diseased structures ; or whether some albuminoid or 
other j)roducts of inflammation obtained admission to the chan- 
nels of circulation, and in that manner gave rise to the systemic 
disorder, is an unsettled point. The 1-atter seems the more reason- 
able view, and in that aspect the disease becomes in its essential 
pathology a cpiasi pyaemia, and calls for similar treatment. This 
consisted of iodide of potassium, in ten-grain doses, thrice 
daily, chalybeates, quinine and vegetable bitter infusions, etc. 
It was inculcated as better i^ractice to cure the co-exist- 
ing gonorrhoea, instead of encouraging urethral discharge, 
under the opinion that its cessation had some influence in origi- 
nating or aggravating the rheumatism. It is much more reason- 
able to think, with M. EoUet, that the abatement of the gonor- 
hceal flow coincidentally with the development of the rheumatism 
is rather the result than the cause of this constitutional mauifes- 

7 



50 



CLINICAL MEMORANDA.— MEBIOAL. 



tation. The patient had likewise ophthalmia, for which he w^as 
treated by Dr. Pope, who may think the case sufficiently interest- 
ing to refer to it in his clinical remarks. 

The cases of alcoholism were due to acute poisoning from over- 
indulgence in drink. They were treated with laxatives, diuretics 
and low diet. This treatment rested upon the assumption that 
the pathology was empoisoned blood, not alone from presence of 
alcohol, but in part due to retarded metamorphosis and altered 
secretion and excretion. When restlessness or insomnia existed 
to a great degree, efforts were made to induce sleep by other 
agents than oi)ium. The following i)rescription often answered 
this purpose well : IjL. Bromide potass. 3ss. j tinct. lupulin or 
tinct. hyoscyamus 3i j water, Ji. M. S. To be taken at bedtime. 

The cases of acute rheumatism were treated, for the most part, 
with alkalies and opiates. The alkalies prescribed were prefer- 
ably the bi-carbonate, the acetate and the nitrate of potash, each 
given in scruple doses, repeated every two to four hours persist- 
ently for the first two or three days of treatment. Whenever 
pain was a prominent symptom in the case, opium was given in 
quantity sufficient to subtract this element of disease. Quinine 
was given in every case, and generally with marked benefit, al- 
though the amendment was sometimes only temporary. It is 
most likely that quinine is v aluable for the treatment of rheuma- 
tism in virtue of its sedative properties, and with this ^'iew of its 
mode of action I gave it in decided doses and quantities. A very 
common prescription was to give five grains conjoined to each 
dose of alkali, until its physiological effects were pretty well 
secured. 

One case of acute rheunuitism deserves a passing notice, on ac- 
count of a course of experimental medication, to the results of 
which the attention of the class was called. It was one of those 
not uncommon examples of rheumatic fever marked by frequent 
exacerbations, or recurrences of both general and local manifesta- 
tions of disease. The i)robability that the pathology of rheuma- 
tism consists in excess of lactic acid is now generally admitted. 
An ingenious author supposes that the fever of acute rheuma- 
tism destroys this accumulation of lactic acid, by means of the 
great increase of oxydization which always obtains under its in- 
tluence, and thus rheumatic fever becomes corrective of its own 
essential cause. lie accounts in this manner for the clinical fact, 



CLINICAL MEMOPwANDA.^MEDICAL. 



51 



tliat those cases of rlieiimatisin in wliich the fever is mildest are 
usually the cases most apt to be marked by returns. With a 
view to test the applicability of these propositions to bedside 
practice, the patient, with his own consent, was submitted to a 
course of treatment designed to increase the oxydating processes 
of the economy. To this end, perchlorate of potash was given in 
ten-grain doses thrice daily. It was simply an effort to substi- 
tute the effects of a purely chemical action of medicine for the 
failure of a hypothetical natural process of cure. The imi)rove- 
ment of the patient for some ten days was extremely flattering 
to hopes of a successful experiment, but after this other relapses 
occurred, in spite of the persistent use of \arious highly oxj^gen- 
ated medicines. 

Chronic rheumatism afforded some good examples for its study. 
The best supported doctrines of its pathology indicate that it 
differs from acute rheumatism only in being engrafted upon some 
state of cachexia general to the system. The prominent clinical 
facts of its greater seriousness as a joint disease, and its lessened 
importance as it respects implication of vital organs and de- 
struction of life compared with acute rheumatism, determine the 
difference in therapeutics. The leading points of treatment insti- 
tuted were directed against the underlying cachexy. Quinine, 
iron, iodide of potassium, codJiver oil and nutritious diet were 
the staple remedies. Whenever local inflammation, and espe- 
cially effusions in the articular or peri-articular structures threat- 
ened damage to joints, blisters were applied, either in close prox- 
imity to or directly over the affected structures. When pain was 
troublesome, it was assuaged by opium. If the bowels were in- 
active, solutions of bi-tartrate of potash or of sulphate of magne- 
sia were exhibited, until this condition was relieved. If there 
was furred tongue, with want of appetite, light mercurials were 
prescribed. Nothing justifies a belief that mercury exerts any 
directly curative influence upon the cachexy of chronic rheuma- 
tism. It is therefore probable that its good effects are due to its 
action in awakening renewed energy in the nutritive processes of 
the economy. 

Five of the thirteen cases of pulmonary consumption are tabu- 
lated, for the purpose of i)reseiiting some of the leading practical 
points connected with them, with the greatest achievable economy 
of space. 



1^ 



■91 ^^mZ 



*9L q^j^ic 



C3 



!=5 5^; C 
1^ O 5 O 



2 

cc c , ^ 



=i £ S 



c " cT « ^s" o 
^ .c r-j o >, X 7^ 



o * ^ 

s: o > 

IT 2 



So'-' 

^ Si -t! i-t 

£-2i«.||-3 



C O 

c S 5 



eS o 



G c -t: 
o 3 c 



3X5 



=^ > 



o 



O '7. 



> 6 
O 



§ > 5 



o i; a: ^ r-i 



r j£ =i o 
s s o 



"o .5 "J:: 



o o 
•43 _ 



ill 



' t. ^ S 

3 _ ^ 



C > 



o 



o 
< 



o o 



3 C 
.2^ 



3 

II 



_ P <y o 
O 0/ o 



cs <-( 

r-i CO r-l 
•-5 



CO o 



3 >s 
= ^ c 

b '5 
3 E 



*3 3 

3 O C 



•12 



'3 ^'.2 



S'.^ 3-' 



^ o 



3 

03 O g 
P- 



3 
O 



= !?-2-2 



s-2^ i::o 



^ 3 



o 
o 
o 
a 
«^ 

Z s 



^ 2^ & 3 
e ^ 



3 « ^ 

C 3 a: 3 
^ g O 

>■ 3 +^ to 
o 3 3^ o 
O cJD 



•5 

00 



3 r3 

o 

3 o 



3 o 
O 3 



«3 «*5 



O >^ a; >3 
3 ,3 

^3.2-^ 

c-f o ^ - 

• 5 

-3 3 Ci l3 

o ^ -r; 



•M ^^^^ 
13 s =^ 



o H ^ 3 ^ 



? i =^ i-- o 

(K r- O 2 

o 3 
^ 1 fci:.2 ^" 3 



o 3 

^ O 3 i f 

.2 X o ^ 



15 '3 



S 



CLINICAL MEMORANDA.— MEDICAL. 



58 



Tlie table inures to the same conclusions wMcli would obtain, 
if the whole number of cases were included. It illustrates the 
connection as cause and effect between elevated temperature of 
the body and retrograde assimilation. In my clinical lectures 
great importance was attached to observations of temperature, 
whether regarding the diagnosis or prognosis of pulmonary tr-ber- 
culosis. As it respects the former point, a persistently elevated 
temperature, not otherwise accounted for, was sulScient to deter- 
mine a doubtful question. As to the latter point, elevated tempera- 
ture imi)lies either increased activit^^ in the process of tuberculiza- 
tion or a more intense degree of irritation attending the deiwsit. 
Indeed it may be formulized as a pathological rule, that abnormally 
high degrees of temperature so surely indicate, or induce, serious 
lesions, that the physician should regard the continuance of such 
a state as a harbinger of danger directly proportionate to the de- 
gree of elevation, and period of persistence. 

All the patients were required to be carefully weighed at stated 
intervals, and their weights recorded. I cannot commend the 
adoption of this custom too highly. It diverts the attention of 
the patient from the diseased lungs, and directs it to that more 
important point, the improvement of his nutrition. Every pro- 
curable article of diet or drink promotive of healthy nourishment 
was urged upon tuberculous patients. They were required to 
take daily out-door exercise, and were encouraged to co-operate 
in efforts intended for their cure by exciting their hopes and by 
keeping them constantly cheerful. Very little was expected from 
medication, directed for any other end than improvement of the 
digestive and assimilative organs. When acid dyspepsia was 
present, the usual prescriptions were thirty drops of aromatic 
spirits of ammonia in half an ounce of infusion of gentian, or bi- 
carb, soda in some bitter infusion. In failure of appetite, quin" 
nine, strychnia, or the mineral acids in infusion wild-cherry 
bark or vegetable bitters were found to be valuable prescriptions. 
Troublesome cough was met by light opiates or other vegetable 
narcotics, or inhalations of medicated vapor. The latter method 
often allayed the harassing cough due to bronchitic irritation, 
when other measures would totally fail. 

The two cases diagnosed as scrofula had both suffered from 



54 



CLINICAL HEMORAXDA.— MEDICAL. 



ulceration of the cervical lympliatics, and Tvere both strongly 
marked with those evidences of innutrition," which, as Xie- 
meyer justly observes, characterize the scrofulous diathesis more 
than all other indications. 

The diseases of the nervous system illustrated remarkably well 
the contrast of symptoms which generally obtains between those 
examples unquestionablj' due to alterations of nerve structure, 
and those ascribable to various forms of irritation whose mode of 
impression and lesions are as yet undiscovered. The hemiplegia 
was referred in three instances to effused clots j in the fourth, 
conjecturally, to embolic plugging ; yet no one of these cases 
exhibited the violent outbreak of symptoms present in those 
examples of neuropathy in which mere nerve irritation gave rise 
to exaggerated or disordered function. It is the difference in dyna- 
mical manifestations between destruction of tissue on the one 
liand, and perversion of normal function on the other. It may 
be farther added that, in those diseases of nerve function 
which seem most certainly ascribable to irritation, neither the ex- 
tent nor the intensity of lesions of nerve structure seems to bear 
any definite proportion to the degrees of resulting irritation." 
Some unknown state of the nervous system, or mode of impres- 
sion exerted upon it, determines not only the nosological com- 
I)lexion of the symptoms resulting from irritations, but their 
intensity likewise. Thus the most violent and interesting case of 
epilepsy was shown quite conclusively to be due to the irritation 
set up by the presence of a tape-worm ; but it is beyond all hu- 
man explanation, that the presence of a tenia should, in one 
instance, produce frightful fits of epilepsy, in another chorea, and 
in a third no manifestations whatever of nerve disorder. 

This patient had undergone tenicide treatment in another 
ward, resulting in the discharge of an unknown number of seg 
ments of the worm. When transferred to my care he complained 
continually of epigastric uneasiness, and was morbidly anxious 
upon the subject of dislodging his supposed tenant. The course 
of treatment ordered was calomel and rhubarb aa. grs. x, to be 
taken at bedtime, and a similar portion to be repeated at the 
same hour the following evening, with |ii pumpkin seed in emul- 
sion to be taken during the interval. He was seized during the 



CLINICAL MEMORANDA.— MEDICAL. 



65 



niglit with epileptic convulsions unusually violent in character, 
and returning so frequently that Dr. Kelly thought it proper to 
give him chloroform and prolong its ansBsthetic influence for some 
hours. I justified his practice, notwithstanding the opposition 
with w-hich it is regarded by high authority. It has the sanc- 
tion of Brown-S^^quard, and the still superior merit of having 
held the convulsions in complete abeyance without any appre- 
ciable bad effect. 

During his convulsions the patient bit his tongue severely, and 
difiacult articulation, amounting to an almost complete loss of 
faculty of speech, followed and still remains. This evidently pro- 
ceeds from paralysis of organs concerned in vocalization, and, 
together with the tongue-biting, points x)retty surely to the me- 
dulla oblongata as a centre of irritation. Tiolent maniacal ex- 
citement followed the fits, and even to this period his mental 
condition and imperfect vocalization prevent any clear informa, 
tion in reference to sense of hearing and taste. Deglutition is 
performed in that convulsive manner which we define by the 
term ^' boltiug." This patient had never been the subject of any 
form of Convulsive seizure previously to this time. The urine 
was never found saccharine. The treatment consisted of sss. doses 
of bromide of i)otassium, in conjunction with 3i syrup of lactucaria 
thrice daily, and pills of gr. i protiodide of mercury and grs. ii of 
extract of conium, given nightly, or sufficiently often to preserve 
sohibility of bowels. Belladonna, in one-third gTain doses, thrice 
daily, and one-twentieth of a grain of strychnia, were substituted 
for the first prescription after a few days. When the diminished 
heat of the head and lessened redness of the conjunctiva indicated 
subsidence of cerebral vascular turgescence, tinct. digitalis was 
prescribed in 3i doses, three or four times daily. A blister was 
applied to the back of the neck and cold to the head. The patient 
has had two or three recurrences of the convulsions. 

The cases of delirium tremens were treated with bromide of 
potassium, digitalis, opiates, and other vegetable narcotics. The 
worst case was attended with obstinate insomnia, delhium and 
aphonia. The prescription which brought the most manifest re- 
lief in this case w-as bromide of potassium, Jss j tinct. digitalis, 
|i J water, fiii. Mix. Tablespoonful every fourth hour. Taking 



\ 



5G CLIXICAL MEMORAi^DA.— MEDICAL. 

a survey of the great number of patients for whom I hare pre- 
scribed digitalis during the winter, I can recall several who con- 
tinued to walk about the wards and hospital grounds while under 
its use, and yet no fact has come to my knowledge confirmatory 
of the observations of Dr. Maudsley. In his excellent treatise on 
the " Physiology and Pathology of the Mind,'^ this author says : 
^' I believe that, though a patient who has taken large doses of 
digitalis may be safe while he is lying down, he is sometimes in 
no small danger of fatal collapse if he starts up or runs about in 
an excited manner.'^ A highly intelligent medical gentleman of 
this city (Dr. S. A. Smith), has observed a fact which leads him 
to concur in this opinion. 

The case of traumatic tetanus was treated by Dr. Ernest Lewis, 
and resulted in recovery. The leading features of treatment were 
persistent use of bromide of potassium, quinine given to ciu- 
chonism two or three times during the jirogress of the case, and 
mitigation cf the most violent spasms by means of chloroform. 
The patient was well sustained by nutritious aliment, and kept 
in perfect isolation and quietude. In this case the physician 
wisely employed his skill in mUigatinrf the violence of symptoms, 
and in not attempting to force their cure. If tetanic convulsions 
can be held in such a degree of control, that they shall not occa- 
sion death by fixation of respiratory muscles or by exhaustion, 
the morbid phenomena gTadually decline, and the case terminates 
in recovery by spontaneous subsidence of the disease. 

The case of chorea offered such slender hopes of benefit from 
treatment, lhat a mere reference to it will suffice. The patient is 
a tall, loosely-formed youth, 21 years of age. While in the Con- 
federate service in 18G3, he underwent a very severe attack of 
measles, followed by paraplegia. As he recovered from the para- 
lysis, the chorea developed itself, and has persisted for more than 
three years. The convidsive movements are incessant, except 
daring sleep, and affect all the voluntary muscles. They bear 
greater resemblance to very exaggerated degrees of paralysis 
agitans than to ordinary chorseic convulsions. Walking cannot 
be performed without the assistance of a nurse, or some form of 
support supplemental to the lower extremities. AVith such his- 
tory and symptoms we could not reasonably conclude that the 



CLINICAL MEMORANDA 



---MEDICAL. 



57 



pathology in this case was confined to mere paresis of the motor 
nerves. Whether we take the view that the chorea commenced in 
centric disease, or that it took its point of departure in the inter- 
nnnciatory system of nerves, there are too many indications that 
its pathology is now connected with structural changes in the 
cerebro spinal axis, to admit of a hopeful prognosis. The treat- 
ment was Fowler's arsenical solution gtt. xii, thrice daily ; bro- 
mide of potassium, 3ss; tinct. hyoscyam, 3i, at bed-time. Strycli- 
nia, iron and cold bathing were also prescribed, and the patient 
enjoined to exert continually efforts of will to gain control over 
the " delirious muscles." 

The following table shows the cases of pneumonia treated in 
my wards, with location and results : 



NAMES. 



'Date of 
iAdmi'rj 



Geo. BradfordlsrNov. 25 



Date of 
Attack. 



Nov. 24 



Luni 



Right 



Jno. Hawkins 40; Jan. IS Feb. 12|Do^ble 



I ^ ! 

Eman. Jominiii66 Jan. 19 Jan. 19! Left 



James Kelly,. 



John Quinn .. 



W. McCarthy 
Thos. Coleman 



i I 
54iMar. 2:Mar. 2: Right 



Result' Date. 
I 



REMARKS. 



Died 



Nov. 30 



39 Jan. 23 

53 Feb. 28 
20 



Feb. li 



Right 



Right 
Left 



Dis'gd 



Died 
Dis'gd 



Tympanitic percussion 
over upper part of 
hepatized lung. 
Feb. 17 Pneumonia followed 
oedema of the glottis 
and laryngotomy. 
Jan. 28 Had been two weeks 
sick of malarial fe- 
ver. Died of As- 
thenia, 

Mar. 14 Old drunkard ; under 
treatment for deliri- 
um tremens ten days 
before attack. Died 
from dysentery and 
exhaustion. 
Mar. 20|Tympanitic pereus^ 
sion under right cla-. 
vicle, 

Feb, 29 Admitted moribund. 
Mar, 1 Admitted for treat- 
ment with malarial 
fever. 



If we rest our estimate of the merits of the treatment adopted 
in pneumonia upon the results exhibited in the above table, it 
would appear scarcely proper to recommend its further adoption. 
But there are facts explanatory of these results. Prominently 
above all others, it will be remembered that every case except 
one (James Kelly) was comi)licated with malarial disease, and 
that one ocurred in a hopeless condition of drunkard's cachexia, 

8 



58 



CLINICAL MEMOEANDA.— MEDICAL. 



The ouly case of double pueiimonia was developed after the 
operation of laryngotomy, performed on account of oedema of the 
glottis. The patient had entered the hospital to undergo treat- 
ment for malarial cachexy and enlarged spleen. On the morning 
of February 9th he complained of sore throat, A very careful 
examination revealed two trivial papules on the velum palati of 
the right side, with very little tumefaction or redness. There 
was not the slightest difficulty of respiration or alteration of the 
voice to attract especial attention to the air passages. During the 
uigiit Dr. Kelly was hastily summoned to find the patient strug- 
gling under the most alarming dyspnoea. The finger readily dis- 
closing the cause, he immediately opened the larynx and inserted 
a canula. The patient was then placed in a curtained bed, and 
the atmosphere kept charged with aqueous vapor at a tempera- 
ture of 80^. The case seemed to progress favorably until the 
14th, when an increased frequency of respira;tions and an anxious, 
flushed fi^ice excited apprehensions of pneumonia. Physical ex- 
amination confirmed the suspicion. There was clulness upon 
percussion over the base of the right lung, with fine crepitation 
in the axillary line about the fourth intercostal space. Every pos- 
sible effort was made to sustain the patient by forced diet, alco= 
holic drinks, quinine and ammonia, but death ensued on the 17th. 
Post-mortem examination showed hepatization, involving the 
third and greater part of the second lobe of the right lung, and a 
part of the lower lobe of the left lung. It revealed likewise in- 
cipient structural changes in the cartilages of the larynx, princi- 
pally affecting the right half of the thyroid. 

The frequency of pneumonia as a consequence of artificial 
openings in the windpipe is admitted as a clinical fact by many 
surgeons. Prof. Schuh, of Vienna, accounts for it by suppos- 
ing til at the currents of in-going air impinging dii^ectLy upon the 
delicate structure of the lungs, instead of being gently admitted 
through a tortuous valvular apparatus, produce the inflammation 
by violence of pressure and distension. AVhatever may be the 
cause, every safeguard judged necessary had been placed around 
this patient. 

The therapeutical indications in the cases of pneumonia were 
so uniform, that there was very little diversity of treatment. 



CLIKICAL MEMORAisDA.— MEDICAL. 



59 



Quinine was given in every case save one, because of an actua 
knowledge of the presence of a malarial element of disease. This 
complication in truth determined the nature of the treatment in- 
stituted. Ammonia, either in solution of the carbonate, or the 
effervescing citrate, and small opiates entered into the list of 
remedies most frequently advised. The last case in the table 
took ten grain doses of Dover's powder every fourth hour, until 
the pleuritic pain was lulled. Linseed poultices or flannel cloths 
wrung from warm water were placed around the chest and covered 
by oil silk. This practice was commenced earl^', and persisted 
in until the process of resolution was well established, or until 
death. Systematic nourishment and liberal use of stimulants were 
more or less necessary in every case. 

In two of the cases of pneumonia there existed tympanitic re> 
sonance on percussing over the hepatized lung. In the first case 
it was not developed until the third day after the attack, and was 
most marked in the third and fourth intercostal spaces, a little 
within the mammary line. In the second case it was i^resent at 
date of admission, and persisted until date of discharge. In the 
latter instance it was most marked in the infra-clavicular region, 
one inch to the right of the sternum. 

Whenever tympanitic resonance is found, aeriform collection 
must be regarded as the postulate of its existence. Either one of 
five different conditions as it respects the seat of such collections 
may be conjectured to give rise to tympanitic percussion sounds 
in pneumonia ; first, true cavity j second, air in vesicles in prox- 
imity to hepatized lung ; third, in the pleural cavity ; fourth, in a 
large bronchial tube perforating the solidified lung ; fifth, in the 
abdominal viscera and transmitted. In each of these two cases 
the aeriform collection was proven to exist in the hepatized lung, 
because of its undoubted connection with bronchial respiration. 
This fact proved also that it did not find its origin in exaggera- 
tion of normal vesicular resonance. The only questions of diag- 
nosis then were j is there a true cavity ? Is there a dilated 
bronchus 1 Is there a large but normal bronclius included in the 
hepatiified lung 1 The second question was excluded because of 
the rare occurrence of such events. The alternative therefore 
was between the first and the last query. The history of the first 



CLIXICAL MEMOEAXDA.— MEDICAL. 



meutioned case gave no support to au opinion that the patient 
had ever been the subject of tuberculosis. The second patient 
had suffered from cough, with abundant expect oratior, night, 
sweats and emaciation one year previous to admission. He had 
never exj^ectorated blood j his appearance indicated a strumous 
diathesis, but he denied any family i^redisposition. and declared 
that his health had been perfect for six mouths directly preceding 
his admission. 

The percussion sound differed as it respects quality in the two 
cases. In the first it was sharper in pitch and transmitted over 
a larger area ; in the second the resonance was somewhat less 
tympanitic, but still contrasted notably with the dull bass sound 
produced by percussing for the sake of comparison over a true 
cavity. In both cases the cracked metal sound was produced when 
the mouth was open. In both instances bronchial respiration coin- 
cided with the tympanitic percussion. In the first case it was 
more intense and brassy" than in the second, while in the 
second these qualities, although modified, still offered points of 
contrast, when compared at the same moment with the characters 
of true amphoric respkation. Tocal resonance was exaggerated 
in both cases j in the former to so great a degree that the clangor 
of the thoracic voice and its proximity to the ear were absolutely 
disagreeable. TThispering j)ectoriloquy was obtained in both cases, 
but more marked and attended with more souffle in the former. 

roist-moriem inspection in the first case displayed the following 
anatomical changes : The right lung was hepatized from base to 
apex, the left was healthy. A former inflammation had united 
the imlmonic and costal surfaces at the anterior and upper part 
of the right chest, over a space fom- inches in diameter. This 
adhesion was continuous and so firm as to be with great difficulty 
separated. Directly beneath this patch a large bronchus was 
situated, with some fourteen lines of solidified lung intervening 
between it and the iiulmonic periphrey. The lung presented no 
evidence of tubercular disease. 

There seems no reason to doubt that in this instance the phy- 
sical signs described had their origin in the bronchus subjacent 
to the locality where they were most marked. A bronchial tube 
of sufficient dimensions to contain a collection of air, this air 



CLINICAL MEMOPvAXDA 



—MEDICAL. 



61 



capable, because of the perviousness of the tube, of being put in 
rapid vibratory motion, and the increased degree of transmitting 
power possessed by an unbroken continuity of tissue between the 
aeriform collection and the ear, constitute a combination of cir- 
cumstances quite sufficient to account for the phenomena present. 
Eminent teachers instruct us that contact of the solidified lung 
with the wall of the chest uniformly gives rise to dull percussion 
sounds. When this rule does suffer derangement from the acci- 
dental location of aeriform collectioi.s in a x)ortion of solidified 
lung in contact with the chest wall, that very circumstance gives 
intensity to the irregular physical signs and additional interest 
to the disturbance of the laws of physical diagnosis. 

I am not able to affirm a diagnosis in the second case, but the 
weight of evidence favored the supposition that a true cavity ex- 
isted. 

"Want of space compels me to refer the class to their notes or 
recollections in reference to many important clinical observations 
connected with diseases of the respiratory system. The cases of 
pleuritis were typical and instructive ', so likewise was the case of 
emphysema. It will be remembered that marked emphysematous 
states of lung tissue were found co-existing with two cases of 
pulmonary phthisis. In both these instances the observation of 
Pollock seemed to be confirmed, that this by no means usual com- 
plication appears to render the progress of consumption less rapid. 
The diagnosis of oedema of the lungs was made in a case of albu- 
minuria, and confirmed by inspecting the cadaver. 

Catarrhal inflammation of the stomach receives but little notice 
from medical authors or teachers, and in consequence of this fact 
I was the more careful to invite attention to the clinical x)he- 
nomena of two very illustrative cases. One case will suffice to 
recall the symptoms and treatment. A fine-looking youth, six- 
teen years of age, employed on a steam-ship, was admitted to 
ward 19 in December, comiilaining of pain in epigastrium, aggTa- 
vated by pressure or efforts to cough. He had a persistent sensa- 
tion of nausea, culminating every four or five hours in an act of 
emesis, in which a considerable quantity of ropy mucus would be 
ejected. The acts of respiration were somewhat accelerated and 
incomplete, because of the pain occasioned by a full inspiration. 



62 



CLIKICAL MEMOKANDA.—MEDICAL. 



Pulse about one hundred, countenance and eyes slightly injected 
and sallow. The lungs were free from evidence of disease. Much 
conversation on the part of the patient produced coughing, which 
did not occur except when provoked in this manner. The treat- 
ment consisted of six grains, of calomel uncombined, followed by 
bi- tartrate of potash, until free catharsis was obtained ; efferves- 
cing draughts ,* cold demulcent drinks j ice j light fluid diet j and 
blister over epigastrium, convalescence was prompt. 

The four cases put down under the head of ascites, were simply 
those examples of hydro-peritoneum in which the cause could 
not be so conclusively proven as to justify employment of a dif- 
ferent classification. In one of these cases the cause was sup- 
posed to be effusion from sub-acute peritonitis, induced by a 
severe attack of dysentery. The accumulation did not manifest 
itself until late in the progress of the dysenteric attack. It will 
be remembered that this opinion was arrived at more by a i)ro- 
cess of exclusion, than because of the presence of the actual 
symptoms of peritonitis 5 nevertheless it receives some support 
from the general premise advanced by Tirchow, that i)eritonitis 
is more often the cause of ascites than has been supposed. The 
patient recovered after three weeks' treatment with twenty-drop 
doses, thrice daily, of mur. tinct. u'on, and painting the heUy 
with tinct. iodine. 

In another case of ascites the patient had received a gun-shot 
wound, i:)assing transversely across the abdomen, and apparently 
including in its course the convexity of the right lobe of the liver, 
there had been a good deal of laceration of the abdominal pari- 
ctes and considerable loss of substance. The liver seemed like- 
wise to be reduced in size, indurated and immovably adherent to 
the wall of the abdomen. The patient had made a good recovery, 
and was in excellent health until attacked by malarial fever, six 
months prior to his entrance into the hospital. lie had continued 
to be harassed by returns of malarial attacks until the date of ad- 
mission. The result had been to produce very marked anaemia 
and considerable enlargement of the spleen. The most interest- 
ing fact connected with the ascites in this case was, tijat although 
the accumulation was not very great, the extensive adhesions 
between the visceral and parietal surfaces had so entirely de- 



CLINICAL MEMORANDA.—MEDICAL. 



C3 



stroyed the elasticity of tlie abdoaiinal wall, that the effects of 
pressure were more troublesome than is usual to very large col- 
lections of serum in the peritoneal cavity. Respiration was very 
much impeded, and the heart pushed far above its normal site. 
Three pathological states may have had each its respective 
degree of influence in producing the ascites in this case : first, 
presumable physical obstruction to circulation from the wound 
of the liver and the enlarged spleen j second, renewal in mild 
form of the peritoneal inflammation ; third, alterations of the 
blood predisposing to serous effusion. The treatment was vigor- 
ous purgation with compound jalap jiowder, repeated as often as 
increased pressure demanded, and restorative measures— quinine, 
chalybeates, etc.=— -during the intervals. 

The third case was probably due to cirrhosis. The patient was 
in a dying condition when received in my ward, and when death 
occurred his friends refused permission for a post-mortem. 

The cases of Bright^s disease occurred in men of robust frames 
and originally good constitutions. One had been a farmer, and 
the other had held some petty oflice on a steamboat. They had 
occasionally indulged too freely in alcoholic drinks, yet neither 
was an habitual drunkard. It has so often occurred to medical 
observers to find albuminuria connected with this vice, that it is 
now regarded as its chief cause. That the ingestion of large 
quantities of alcohol should give rise to diseased conditions 
of the uriniferous tubules is readily explained by the physi- 
ological fact, that the kidneys are the emunctories through 
which the unchanged alcohol is principally removed from the sys- 
tem. It is a recognized fact in pathology, that those organs 
which assume the office of ridding the system of the presence of 
a poison, do so at the hazard of their own integrity. It is, then, 
perfectly rational to connect the lesions of the kidneys with the 
office which they execute, of eliminating a poison whose contact 
is highly irritative to their delicate epithelial structure. 

Several clinical facts connected with these cases were worthy of 
note. First, they illustrated the important fact, that patients may 
be the subjects of very advanced states of Bright's disease with- 
out being cognizant of any renal difficulty. In one of these cases 
the daily secretion of urine was less than ten ounces, and yet the 



64 



CLINICAL MEMORANDA.—MEDICAL. 



patient was not aware of any changes in amount or cLaracter of 
his urine until my investigations determined them. Next, they 
illustrated the fact that, in advanced stages of the disease, the 
diminution of the amount of albumen in the urine is by no means 
an absolute indication of improvement ; on the contrary, its dimi- 
nution, or even disappearance, may indicate the progress of those 
more profound conditions of degeneration from which recovery is 
utterly hopeless. According to Cornill, fatty degeneration inva- 
riably produces diminution of albumen in the urine in proportion 
to the degree and extent of the chauges it has effected in the 
kidney. This author also quotes E an vier, as saying that "albu- 
men and fat do not seem to be formed at the same time and in 
the same cell.'^ In both of these cases the amount of albumen 
was greatly diminished for several weeks before death— almost 
altogether disappearing in one case. 

The prognosis of albuminuria depends upon its pathology. 
There are three morbid conditions which may each determine its 
appearance : First, altered mechanism of the circulation by pres- 
sure J second, alterations of the blood ; third, disease of renal 
epithelium. When due to the first or second cause, it is more 
likely to be temporary and curable ; when to the third, it is always 
serious. While very little hope was expressed of obtaining bene- 
fit from any measures intended to cure these two cases, it was 
determined nevertheless to try the mode of treatment recently 
adopted by Niemeyer in several cases of Bright's disease, reported 
to the medical faculty of Tubingen. This consisted in confining 
the patient to milk for diet, and in promoting cutaneous transpira- 
tion by occasional baths and x>i'otecting the surface from cold. 
No medicines were given, except twenty drops each of mur. tinct. 
iron and tinct. digitalis, thrice daily. The patient's progress 
under tliis treatment was so satisfactory, that I shall not hesitate 
to adopt it again, and watch its results under circumstances not 
so decidedly unfavorable. 

The cases of diuresis were sim^^ly examples of excessive func- 
tional activity, and yielded promptly to treatment. One of the 
l)atients had fallen from the deck of a steamer into the water, 
and the disorder was ascribed to this cause. The daily amounts 
of urine excreted ranged from ninety to one hundred and ten 



CLINICAL MEMOEANDA — MEDICAL. 



65 



ounces. The treatment was five grains sulphate of iron and am- 
monia, three times daily ; ten grains of Dover's powder at bed- 
time, and restriction in the use of water or fluid ingesta. 

In the case reported as lardaceous liver and spleen, tlie diag- 
nosis was arrived at by exclusion. The patient was a seaman, 
thirty-one years of age. Some, two, or three years before admis- 
sion he contracted syphilis, for which he underwent a tedious 
course of treatment. The evidences of syphilitic cachexia were 
not strongly impressed upon his constitution, and in truth were 
almost altogether limited to marks of suppuration of some of the 
inguinal glands. For two years he had suffered frequent but not 
violent attacks of intermittent fever. When admitted to hospital, 
on the 24th of October, 1867, the patient's abdomen was very 
much distended with serum, and this symptom, with enlargement 
of the superficial abdominal veins and the dull sallow hue of the 
skin usually co-existing with acholic jaundice led to a diagnosis 
of cirrhotic liver. The treatment directed for the patient wa^i 
mur. tinct. of iron, tinct. digitalis aa 3ii tinct. nux vomica 3i 
M. S. Give fifty drops three times daily. Also the following- 
mixture was to be taken at will in the course of each twenty-four 
hours: IiL Bitarfcrate potass ^i j infusion juniper berries Oj M 
Nitro-mur. acid .and salt water frictions were ordered to be made 
over the region of the liver. After a mouth's persistence in meas- 
ures of treatment which did not vary essentially from the above, 
the patient was completely relieved of the ascites; so that better 
opportunities were aiforded for determining the condition of the 
abdominal viscera. I may remark in passing, that on more than 
one occasion I repeated the opinion, that the diuretic treatment 
had little or no agency in removing the ascites. It is extremely 
unlikely that any form of medication would increase renal secre- 
tion, with such an amount of pressure upon the blood-vessels as 
must have existed in this case. I supposed the removal of the 
dropsical accumulation due to relief of the obstructed hepatic 
circulation, by the gradual enlargement of compensatory channels 
through which the blood Avas reti,irned to the heart ; and in part 
perhaps, to an improved condition of the blood, as it respects its 
own composition. Whatever may have been the cause, after the 
removal of the serum, the flaccid, thin abdominal walls enabled 

9 



66 



CLINICAL MEMORANDA.— MEDICAL. 



US to determine tliat the liverj especially tlie left lobe, was mucli 
enlarged and hardened. This latter condition was rendered ob. 
vions, when the lower edge was grasped between folds of the 
abdominal wall and subjected to pressure. The liver extended 
laterally to the boundary of the left hypochondrium, and in- 
feriorly to the sui^erior margin of the hypogastric region. Its 
convexity was very greatly increased, but the lower border re- 
tained its normal thinness and sharpness of outline. The right 
lobe appeared to be diminished in size. The spleen was very 
much enlarged and unusually resisting to pressure. A well de- 
fined fissure not more than one inch in width, separated the two 
organs, while the lower extremity of the spleen reached the left 
iliac region. The urine ot the patient was normal in quantity and 
characteristics. The patient's bowels were variable as it respects 
solubility, but were readily excited by purgatives. Prof. Mallet 
analyzed two or more specimens of the stools, and found a de. 
ficiency, almost amounting to complete absence, of biliary coloring 
matter. The patient had no iiulications of tubercles or history of 
any hereditary tendencies. He stated that he habitually drank 
whisky, and generally drank it neat," bat denied any excessive 
use of it. Some months before admission he had suffered pain in 
right hypochoudrinm, succeeded b^^ jaundice, which had persisted 
for a number of weeks. Since the date of first attack his bowels 
had been in the variable slate above desciibed, fluctuating be. 
tween slight costiveness and diarrhcea. The diagnosis which 
affords the most satisfactory explanation of the morbid states and 
phenomena entering into this clinical history, is tliat the right 
lobe of the liver has undergone cirrhotic changes and diminution 
of size, while other portions of this organ and the spleen are the 
seats of lardaceous deposit, aiul are enlarged. Dr. Wilks includes 
in his valuable report on lardaceous disease several instances, in 
which these two pathological states were found affecting different 
portions of the same liver, or indeed almost interlacing with 
each other. The difficulty in arriving at a defensible diagnosis in 
structural changes of the liver is so well expressed by Dr. Wilks, 
that I quote the language lie employs : " Indeed it is veiy re. 
markablc that, although liver complaints (as they are styled) are 
more spoken of by medical men than almost any other maladies? 



CLINICAL MEMOPvAXDA.— MEDICAL. 



G7 



yet that no organ lias so few cliaracteristic or positive signs of 
structural derangement." 

Of course, little or no good could be produced from the use of 
medicines in tliis case. The perverted chemistr}' or physiology 
of these disorders of remote nutrition is too little understood to 
enable us to premise successful medication. It was thought that 
some good influence might be obtained by efforts to combat the 
supposed syphilitic diathesis, and for this purpose one-sixteenth 
of a grain of bichloride of mercury was given in 3i fluid extract of 
sarsaparilla, thrice daily. The patient left the hospital during 
the month of March. 

I have exceeded the limits assigned me, and yet have left many 
interesting examples of disease without notice ; but it is to be 
l^resumed that a class as studious and faithful as that for whose 
benefit these memoranda are published, has not failed to derive 
the full measure of profit from the unmentioned as well as the 
mentioned cases. It has been my desire to make this, as far as 
possible, essentially a resume of the clinical facts and j^recepts 
brought to the notice of the classy consequently it has appeared 
to me just as important to recall some of the points of pathologi- 
cal doctrine mentioned in connection with various cases, as the 
clinical facts. This explains the introduction of speculations as 
to the nature of the various diseases discussed in this paper. 



Aet. X. — Xotes OH a case of Thromhosis and Emhollsm^ and of 
otlier Lesions occurring in Yellow Fever : By SxAxpoED E. 
Chaille, M. D., Professor of Physiology and Pathological 
Anatomy, Medical Department University of Louisiana. 

The researches and experiments of Yirchow and his co-laborers 
on the coagulation of the blood in living vessels, and the convey- 
ance of minute clots or foreign substances (whether produced 
pathologically or introduced experimentally,) througli the circula- 
tion to be arrested in the capillaries, or other vessels too small 
for their passage, producing in the tissues supplied thereby 
hiTemorrhagic infarcti, fatty, purulent, and other degenerations, 
have served as a new era in pathological anatomy ; and furnish 



63 



CLINICAL MEMORANDA.— MEDICAL. 



positive demoDstration of many pbenomena, wliicli were before 
the subject of unsatisfactory coDjectures only. 

All facts connected with this interesting subject are worthy 
of record, and the case now reported, deserves additional interest 
from the fact, that no similar one (so far as is known) has ever 
])een observed or pi".blished in connection with yellow fever. 

On September 10th, 1867, Daniel Gavin, aged twenty-two, was 
attacked by yellow fever, characterized hj the severity of the 
symptoms and great prostration. Within a week, profuse and 
obstinate epistaxis occurred, followed by bloody abscesses on the 
arms and legs. One ot these on the right wrist was opened, and 
healed favorably. From the 23d to the 27th, pr?ecordial pain and 
oppression, weak, rapid pulse, dyspnoea, and some ascites were 
observed. On the 27th occurred paroxysms of dj^spnoea and 
coughing, with viscid exijectoration, and a severe chill. The 
rigors reoccurred on October Sth, 13th, 30th, and November 5th, 
between which dates the dyspnoeal paroxysms were often rei^eat- 
ed, and profuse diarrhoea made its appearance. On 'Nov. 7th he 
died. 

Between October 20th and 30th this patient (not in my charge) 
was first sern and was then suffering with a paroxysm of dysp- 
noea, which so seriously interfered with respiration and circula- 
tion, that it vras confi.dently believed that the autopsy could be 
made on the next day. These dyspnoeal i)aroxysms, and the 
following phenomena gave to this case its peculiar interest. The 
liatient presented a singularly bloated, swollen, livid appearance, 
limited to the right side of the face and head, neck, arm, and 
upper part, (pectoral muscles chiefly) of the thorax ; all of which 
were very oedematous, and darkly discolored. The swollen su- 
perficial veins of these parts were in marked contrast to those of 
the left side and though the habitual decubitus was on the 
right, a protracted change to the left side did not diminish the 
local oedema and discoloration. 

It was evident that such a condition must have for its cause 
some local impediment to the return of the venous blood from the 
parts to the right heart, and a thrombus was confidently diagnosed. 
Confirmation of the diagnosis followed in a few days when the 
jugular was found hard and corded. The condition of the patient 



CLINICAL MEMORANDA.— MEDICx\L. 



69 



was such that the application of auscultation and i)ercussiou, 
particularly the latter, was painful, difficult and unsatisfactory; 
which added to the consideration that a fatal result was not 
doubtful, caused less thorough examination cf the thoracic organs 
than was needed to decide correctly their exact condition. How- 
ever, it was established that the action of the heart was weak 
and tumultuous or perturbed; but no friction sounds nor cardiac 
bruits were detected. The physical signs of bronchitis and pul- 
monaiy congestion were manifest over a large extent of both 
lungs, but to a greater degree on the left side. 

The post-mortem examination was made in preseiice of the 
clas» by the writer, who stated prior to the autopsy, that it was 
a case of thrombosis with embolism, accompa^.iied by such other 
symptoms and morbid anatomy as were frequent in blood-poison 
diseases. Timt the general symptoms belonged especially to that 
misnamed disease pysemia, for which it was better to substitute 
a more non-committal term, as septicieinia, since modern re- 
searches had proved that blood was not poisoned by healthy pus. 
That those blood diseases which were frequentlj^ accompanied by 
symptoms of pyaemia, were the diseases which were the most 
often complicated with thrombosis and its resulting embolism. 
That the fibrin of the blood underwent changes in these diseases — 
some, as Eokitansky, asserting that it was augmented, others 
that it was diminished in quantity; but all agreeing that it was 
impaired in quality ; that it was taught, that one of the results 
of this impairment in quality was an augmented tendency to 
coagulate — a tendency which the feeble action of the heart and a 
retarded circulation, always present in these cases, increased. 
As a result of such change, there sometimes occurred a coagula- 
tion of the blood in situ (thrombus), from which particles (emboli) 
were washed into the circulation, and were necessarily arrested 
in the first vessels too small to permit their passage. Modifica- 
tions in the nutrition of the tissues, thus cut off from their nu- 
trient fluid, followed, and thus were formed hcemorrhagic infarcti, 
fatty degenerations (limited), softening of isolated parts of the 
tissues, as the cerebral, and multiple abscesses. That the infarcti 
resulted from occlusion of an arterial vessel by an embolus, 
thus arresting circulation in all its branches, in which therefore 



70 



CLINICAL MEMOEANDA 



—MEDICAL. 



coagulation took"place; and that as arterial vessels brancliecl off 
divergently from the original vessel as their apex to the periphery 
as their base, therefore that infarct i were conical in shape with 
their base towards the surface of the organ affected That these 
haemorrhagic infarct! differed from apoplectic hsemorrhages, in 
that the blood in the former v/as inside, in the latter outside of 
the vessels, and that these infarcti, at first htemorrhagic, were 
subject to degenerations, of which the fatty was one, and puru- 
lent degeneration a more advanced stage. That, to explain why, 
when the .V, hole mass of blood had undergone this tendency to 
coagulation, it manifested this tendency in certain parts of the 
circulation, demanded a s( arch for local causes, an investigation 
which often proved profitless. 

It was stated, that other anatomical lesions were frequently 
present, due to changes in the blood, changes not at all under- 
stood ; and that among these lesions inflammations of the serous 
membranes were the most frequent. That no undue weight might 
be given to the ocurreuce of thrombosis and embolism, it was well 
to bear in mind that the conditions in which they ocurred were 
generally fatal, even though these complications were wanting. 
For these reasons, it was confidently anticipated that thrombi 
w^ould be found in the veins leading from the discolored and 
cedematous i^arts, and that ha^morrhagic infarcti with multiple 
abscesses would be found in the lungs, as embolism was a legiti- 
mate child of thrombosis. In addition, that the serous mem- 
branes required a close examination. 

Autopsy. — Vessels — The right subclavian and internal jugular 
veins, from their junction and for some distance of their extent, 
were found completely occluded, in part by coagulated blood, but 
in chief by a fluid exactly lilce pus in appeanmce. This occlusion 
extended into the terminations of the external jugular, brachial 
and cephalic veins ; and the farther from the heart the occlusion 
extended, the more the venous contents approached the appear- 
ance of coagula and the less of pus. 

Lungs — Considerable congestion and innumerable multiple ab- 
scesses, each containing only a few drops of purulent fluid, were 
l)resent in both lungs, as also small infarcti. On the surface of 
the lower lobe of the left lung was found an infarctus fully as large 



CLINICAL MEMORANDxV.— MEDICAL. 



71 



as a pigeon's egg, indicating the occlusion of a vessel of consid- 
erable size. 

PJeurce — The surfaces of the thoracic and i)ulinonary pleuris 
were extensively and firmly agglutinated by false membranes. 
In the diminished pleural cavities still remaining was found a 
considerable quantity of serum and fibrinous coagula. 

Pericardium and Heart — Evidences of extensive and severe in- 
flammation of the pericardium existed; false membranes bound 
it around the base, and also to parts of the apex of the heart. 
Its cavity was filled with bloody, turbid serum. The endocardium 
and valves Avere free from disease, and the vessels attached to 
the heart contained no coagula of note. Between the pericardium 
and diaphragm was an abscess containing not less than a table- 
spoonful of pus. 

Kidneys and Liver— The kidneys like the lungs contained nu- 
merous multiple abscesses, and like the liver were congested. 
The liver Avas in other respects normal. 

Brain — Its lateral ventricles contained some bloody serum, anil 
beneath the arachnoid, blood, iu small quantity, was extrava- 
sated. The cerebral parenchyma was somewhat soft, but uni- 
formly so. 

Careful examination foiled to detect any other lesions. 

Eemarks. — Many eminent authorities have maintained that 
there is a necessary sequence of cause and effect between phle- 
bitis, thrombosis with embolism, and pyaemia ; the first causing 
the second, and these the last. The facts in the i)resent case fail 
to support this view, and are better explained by the supposition 
that the pyremic symptoms and the thrombosis were both effects 
of the same cause, i)oisoned blood ; the former being a general, 
and the latter a local manifestation of this cause. In this case 
the chief symptoms of i)ycemia were well marked antecedent to 
any signs of thrombosis. Earther, it would be very difficult to 
believe that the emboli, necessarily conveyed to the right heart 
could traverse the pulmonary capillaries, and then passing into 
the arterial circulation be arrested by the renal capillaries only. 
For the kidneys were the sole organs supplied from the aorta 
which contained the multiple abscesses or any other of the lesions 
of embolism — and such abscesses in yellow fever kidneys are not 



72 



CLIKICAL :^[EMOBANDA.— MEDICAL. 



iufrequeiitj iudependeut of all causes to suspect either embolism 
or pyaemia. Therefore it is believed that the renal, as well as the 
lesions of the serous membranes preceded and were independent 
of the coagula and puriform fluid found in the veins, whilst the 
local oedemas and pulmonary lesions were caused thereby. To 
the thrombosis and embolism I was also inclined to ascribe the 
very remarkable paroxysms of dyspnoea which had been observed. 

Too little is known of the pathology of thrombosis to furnish 
satisfactory explanation, or conjecture even, as to why the blood 
should have selected the junction of the internal jugular and sub- 
clavian veins, where local impediments apparently so little exist, 
as the site of its coagulation. Formerly a local phlebitis was 
confidently assigned as the cause, but in this as in cases reported 
by others, no evidences of such inflammation existed. Once it 
was dogmatically taught that the presence witliin the veins of 
a fluid having the appearance of pus was ample proof of phlebi- 
tis. Modern pathologists have abandoned this view j for Virchow 
and others have proved that the iuterual coat of veins when in- 
flamed never exudes pus ; — and Gulliver has demonstrated that 
the fluid found within the veins though puriform is not pus; that 
it is coagulated fibrin which has undergone its ordiuaiy degene- 
ration, converting it into a granular oily matter which possesses 
r either the microscopical nor chemical character of pus, and is 
the same process by which the fibrinous coagula, which fill up 
the air vesicles, and thus consolidates the hepalized lung of pneu- 
monia, are softened and removed from the economy j that this 
change always begins in the centre of the clot and not where in 
contact with the venous walls ; and farther that coagulated fibrin 
when removed from the body, and exposed to a blood heat begins 
to soften and to undergo this puriform degeneration in forty 
hours. Other microscopists have confirmed these views. On 
such subjects the authority of no one is higher than Kobin's, who 
in his recent work (1867) " Sur lesllumeurs," dwells with marked 
emphasis on the assertion, that the i)us-like fluid, found within 
veins is degenerated fibrin, not pusj and that such corpuscles as 
niay be present are white-blood, and not pus corpuscles. A re- 
cent opportunity enabled me to examine an ante-mortem clot. 
An incision into its centre disclosed a puriform fluid, (deemed the 



CLINICAL MEMOKANDA —MEDICAL. 



73 



surest evidence of an old ante-mortem clot) which under the mi- 
croscope had not the characters of pus. 

The only part now assignable to phlebitis as a cause of throm- 
bosiSj and in some cases of pysemiaj is, that by it the venous walls 
are rendered thicker and rougher, which conjoined to other t3ir- 
cumstances promote coagulation. The coagula may undergo 
softening, and cause dangerous embolism, and as a sequel of this, 
pyaemia may or may not be produced, depending on unknown 
circumstances. However indefinite and unsatisfactory this state- 
ment may be, it is not the less true that scientific accuracy will 
not justify any more absolute assertion. 

NOTES ON THE PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

It is very much regretted that circumstances prevented satis- 
factory researches into the pathological anatomy of last year's 
epidemic. Arriving in the city in October, when the fever was 
on the decline, and finding that i)ost-mortem examinations were 
prohibited by military authority, little could be done. In all, less 
than a dozen autopsies were made. The results of these may 
prove of some interest. 

Even recent European authorities continue to repeat in their 
text books the assertion of Louis, that the cafe au lait " liver is 
the characteristic lesion of yellow fever. jSTot exceeding one-half 
the cases examined presented this appearance, and established 
the fact repeated by every author in this city, that this lesion of 
the liver, whilst frequent, is not characteristic. These livers were 
microscopically examined for fatty degeneration, which was 
found, but by no means in exaggerated degree. Most observers 
report this condition as constant j but Prof. Eiddell found it 
though frequent, not constant. 

La Eoche quotes Cartwright and others to the effect that lesions 
of the solar plexus are constant. It is true that in the tissues 
around the plexus, as in all similar tissues, as dependent, evidences 
of hypostasis are manifest ; but the nerve tissue itself, examined 
carefully in six cases might have been selected as perfect types of 
normal structure. 

In no case examined were the kidneys healthy. Extreme 
ftiability characterized them all. They were enlarged, congested, 



1i 



CLINICAL MEMOEANDA.— MEDICAL. 



and beneath the membrane forming the pelvis, infundibulse, and 
calyces, were found petechise, ecchymoses, or other evidences of 
extravasated blood. In two cases the kidneys presented multiple 
abscesses, and in several cystic degenerations, which latter how- 
ever were not ascribed to the yellow fever. In one case coagulated 
blood blocked up the renal vein of one side ; which it was believed 
was ante-mortem, because the vein was solidly impacted and the 
clot present on one side only. Prof. Bemiss states that his re- 
searches show that albuminuria is not constant in yellow fever. 
That it was present in the first stage in some cases, in the second 
stage in a much greater number of cases, and very rarely absent 
in the fatal cases. 

It is still discussed whether gastric inflammation is not, a 
necessary lesion, and the cause of some of the chief symp- 
toms of yellow fever. To those unaccustomed to post-mortem 
examinations, and this exception reduces the number of com- 
petent observers to an extremely limited number, no fact seems 
clearer than that yellow fever stomaclis present abundant evi- 
dence of inflammation. Its mucous lining is found swollen, 
softened, eroded, congested, blackened. 

The remark is as old as John Hunter, that there are very few 
dead bodies in which the stomach is not in some degree digested. 
The post-mortem results of gastric self-digestion are well under- 
stood, and are present in variable degrees in all cases — from 
erosions perhaps invisible to the naked eye, to perforations and 
the most extensive destructions, not only of the stomach itself, 
but of the adjacent tissues. If a rabbit be well fed, and then 
killed, and the body kept at a temperature of lOOoF., over night, 
the most extensive ravages, even to i)erforation of the abdominal 
parietes result. But, though these facts are known, very few 
have habitually observed them in the dead house or laboratory ; 
and therefore their opinions as to the lesions which distinguish 
gastric inflammation, from the post-mortem changes in the stom- 
ach, very variable in degree and totally independent of disease, are 
comparatively Avorthless. Eokitansky regards gastric softening 
as always cadaveric, and of two kinds, the gelatiuiform or white, 
and the black raraollissement. The latter occurs whenever the 
gastric vessels are gorged with blood 5 and is the condition most 



CLINICAL MEMOIIANDA.—MEDICAL. To 

frequent iu yellow fever, of wliicli tlie only true gastric lesion is 
vascular engorgement, resulting often in rupture of the capillaries 
and extravasation of blood ; wliicli mixed witli and altered l3y the 
gastric secretions constitutes the black vomit. 

Whenever pathologists admit that the soft, spongy, swollen, 
bleeding gums so frequent in yellow fever owe this condition to 
inflammation, then they may admit that the gastric lesions are 
also inflammatory, but not before. Drake quotes Prof. Stone as 
reporting, many years ago, in regard to the gastric lesions that 
they were very marked, especially iclien the examination teas post- 
]}oned. It is not difficult to appreciate the sarcasm lurking in this 
remark. 



Art. XI. — Cases of Eye Disease^ Reported by Dr. B. A. Pope, in 
Charge of the University Eye and Ear Clinic. 

Case 1st. — Traumatic I>isJocation of the Lens into the Anterior 
Chamber. Flap Extraction. Chloroform Administered. — T. E., 
aged fifty years. While at a fire, received the stream from 
the hose of a steam fire Engine against his left eye. The sight 
<)L the eye had been i)reviously extremely imx^erfect. Ten days 
after the injury he presented himself at the clinic, and was sent 
to the Charity Hospital. He stated that he had the day before, 
for the first time, observed that the eye was inflamed. The pu- 
pil was completely dilated, and the lens and the iris were both in 
contact with the cornea. The next morning I found that severe 
inflammation had commenced. There were intense pain and 
photophobia, and the upper lid was much swollen. The chemosis 
was very considerable, but mostly of a serous character, The 
lens was of an amber color, with but a moderate amount of corti- 
cal substance, which led me to believe that it was a case of pre- 
viously existing cataract, which had been dislocated by the blow 
received. 

The indication was to extract the lens immediately by the flap 
operation, the lens being evidently hard, though apparently 
not very large. It was found necessary to make incisions with 



76 



XCLIICAL MEMOEANDA. 



—MEDICAL. 



the ocular coiijuuctivaj iu order to bring tlie cornea into view 
sufficiently, it being partially covered by tlie swollen and flabby 
conjunctiva. In a few minutes the serum was sufficiently drained 
away to allow tlie performance of tlie operation. 

The flap was made upwards, and smaller than in ordinary 
cases, for the lens seemed small, and it was evident that the 
vitreous must escape as the knife was withdrawn. There being- 
no anterior chamber, it was necessary to pass the knife through 
the iris and lens. As was expected, the vitreous in a partly fluid 
condition followed the knife, and filled ux> the opening in the 
cornea. The cornea was found to be quite thin, and deficient in 
elasticity, though the diameter was normal. As the vitreous humor 
escaped the luipil partly contracted, but the upiier i^art of the iris, 
including the impillary margin, was carried back into the liquid 
vitreous humor against the ciliary body. This was caused by the 
fact that the vitreous humor followed the knife as it was withdrawn, 
and getting in front of the iris pressed it backwards thus, pre- 
venting it from passing into the corneal opening. The vitreous 
being to a great extent liquified and escaping, it was of course 
difficult to get the lens to move towards the corneal opening ; 
besides it had already been displaced somewhat downward by the 
escaping vitreous. Instead of making the usual manipulations 
for extracting the lens, which would only have increased the flow 
of the vitreous humor, gentle pressure was used on the cornea 
fi^om below upwards, which gradually approached the lens to the 
corneal opening, when it was seized by an assistant, and removed 
without difficulty, and with but little additional loss of vitreous. 
Xot more than a fourth of the vitreous escaped during the opera- 
tion. The perfect apposition of the lips of the wound was every 
where prevented by the presence of the more solid portions of the 
vitreous J still there was but slight separation, on account of 
the small amount of solid vitreous. The lids were closed by 
means of strips of adhesive plaster, and a soft compress and ban- 
dage were applied, so that uniform and gentle pressure was 
exerted upon the eye. 

The dressings were removed sufficiently on the second day for 
the purpose of using a solution of the sulphate of atropia. On 
the third day the eye was examined, and it was found that 



CLINICAL MEMOKANDA.— MEDICAL. 



77 



though the wound was closed the uniting material was much 
stretched by the internal pressure which had partially forced the 
iris against the wound. The next day I opened the wound at about 
the centre, and evacuated a small quantity of vitreous ; but 
failed in seizing any portion of the iris, which sank back when 
the vitreous escaped. The imperfect application of the lips of the 
wound caused a transverse fold in the cornea, running from one 
extremity of the wound to the other, in a straight line. After 
the operation all symptoms of active inflammation subsided. 
The patient was very restless, and several times removed the 
dressings from the eye. Gradually the cicatrisation of the wound 
was com]3leted, so that after about two months he left the hos- 
pital, with very good sight, and but slight remaining irritation 
of the eye. The pupil was displaced upwards, and was of the 
shape of a half moon. 

RemarlxS. — The capsule of the lens had been ruptured by the 
blow upon the eye, and the slow development of the inflammation 
under such circumstances was an additional proof that the lens 
was cataractous at the time the injury was received. It is well 
known to ophthalmic surgeons that the contact of the normal lens 
substance is a source of great irritation to the iris. Even the 
cortical substance of a ripe cataract, when left in the anterior 
chamber, is often the cause of iritis after cataract extraction. 
Another great danger from dislocation of the lens into the ante- 
rior chamber, with the escape from the capsule^ is the sweUing of 
the lens substance, by imbibition of aqueous humor. The too 
rapid imbibition of aqueous humor is the principal source of 
danger in the operation for cataract by discision, the swelling of 
the lens substance (cortical) causing increased tension of the eye- 
ball (increased intra-ocular pressure) and inflammation. If the 
imbibition is very rapid, it may lead to total destruction of the 
eye, unless the lens substance should be removed by operation. 
In the case just given, notwithstanding the trauma and the rup- 
ture of the capsule, with dislocation of the lens, the inflammation 
up to the tenth day was very slight. Had there been a normal 
cortical substance this could not have been the case. The lens 
was of an amber color, and in addition the cortical substance 
small in quantity, but little changed by contact with the aqueous 



TS 



CLINICxVL MEMOKAIS DA.— MEDICAL. 



humor, ajicl x)resented nothing to distinguish it from the soft cor- 
tical substance of a completely ripe cataract. 

For the above reasons it is almost certain that cataract pre- 
viously existed, and that this case cannot be considered to be one 
of traumatic cataract, and should not influence the formation of 
an opinion as to the dangers of such an accident. In such a case 
the indication is for immediate operation. 

Case 2. — Irdernal Strahismus.—Jj. F., fourteen years old. When 
three or four years old his eyes began to become crossed. An exact 
history v, as not to be obtained. The right eye alone was aftected. 
The degree of the strabismus was about three and a half lines. 
When the left eye was covered, and the patient was directed to 
look as far as possible to the right, the motion outwards was al- 
most perfect, and about equal to that of the left eye. As a rule, 
the motion outwards of tlie affected is less than that of the unaf- 
fected eye. The accommodative movements were normal. The 
sight of the eye was reduced to reading Ko. 10 of Yaeger's text 
print. The eyes both departed from the normal refractive stand- 
ard, so that it required convex lenses of thirty inch focus before 
the eyes in order to place them under oi^tical conditions similar 
to those of normal eyes. The normal refractive standard is as- 
sumed to be the power to unite parallel rays of light upon the 
retina when the accommodative i^ower of the eye is in a passive 
state. 

The patient was placed under the influence of chloroform, and 
operated u^Don in the following manner : 

An opening of about two lines in length immediately over the 
insertion of the rectus internus was made. The posterior margin 
of the wound was seized wdth the forceps and distended, so that 
the conjunctiva could be dissected with a pair of sharp-pointed 
scissors from the eye-ball, as far down as the semilunar fold. The 
tendon of the muscle was then seized with a strabismus hook, 
and divided close to its insertion into the sclerotic coat. The 
division was perfectly made, so as to get the full effect of the 
operation. The conjunctival wound was then closed by a single 
suture. 

The deformity was corrected, and in an hour after the patient 
could see hetter with the ej^e operated on. In the course of a few 



CLINICAL MEMOEAKDA.— MEDICAL. 



79 



weeks tlie siglit of tlie affected eye was almost as perfect as tliat 
of the other. There was hardly a trace of the operation, and the 
deformity was entirely cured. 

Remarhs. — This case is introduced in order to call attention 
to the importance of operating early in cases of strabismus. It 
belonged to the most favorable class, and the surgeon could run 
no risk in promising an almost perfect result, provided the 
operation was properly performed. It is, as a rule, unsafe to al- 
low a case to remain without operation as long as this did. I 
have recently operated on a case in which the sight had been 
much more injured and remained without improvement, not- 
notwithstanding the patient was about the same age, and the 
case did not differ essentially from the one just described, except 
that binocular vision was no longer possible, even when prisms 
ware used. The closest examination led to the discovery of no 
other cause for the strabismus, than the deficiency in the refrac- 
tiv e power of the eyes. It is true that many cases are observed 
in which this imperfection exists in a high degree without caus- 
ing strabismus, still so large a proportion of cases of strabismus 
internus are affected in the way that we are justified in the as- 
sumption that this is the cause. The degree of this imperfection 
causing strabismus internus is not a fixed one, consequently there 
must be in this class of cases some other influencing cause or 
causes, which most probably are to be sought for in the internal 
and external muscles of the eye, in irregular refraction of light, or 
in some defect in the anatomical relations of the retina. 

Case S.-^Iritis; Treatment and Cure tvitJiout use of Internal 
Eemedies. — D. D., sailor, aged thirty-one years. The patient said 
that he had had a syphilitic skin disease about five years since. 
About 14 months since he had rheumatic pains in his shoulders 
and hips. His clavicles were "sore" at the time. For twelve 
months past he has had a slight redness of the right eye, but never 
had a decided inflammation till about a week ago. At that time 
he had a pain in the ballj especially when moved suddenly. Look- 
ing downwards was particularly painful. The pain was not con- 
stant. When he presented him self for treatment, he was suffering 
from severe throbbing nocturnal pain in the eye and photophobia. 
There was at intervals some pain during the day also. The upper 



80 



CLINICAL MEMOKANDA.— MEDICAL. 



ej^elid was somewhat swollen, especially towards the lower part, 
and the patient could hardly raise it. There was a free flow of 
tears with some mucus. The palpebral conjunctiva was of such 
an uniform scarlet red, that one not experienced in the diagnosis 
of eye diseases might well have supposed the case to have been 
one of catarrhal conjunctivitis. The whole ocular conjunctiva 
was red, but the redness increased in intensity from the conjunc- 
tival cul de sacs up to the margin of the cornea. The usual zone 
of sub-conjunctival injection around the cornea was present, but 
was i)artially masked by the conjunctival injection which was 
most intense in the same zone. The cornea was perfectly healthy. 
The iris was changed from blue to a decided green color. The 
pupil was contracted and motionless. The iris was somewhat 
swollen throughout. The aqueous humor was slightly turbid, but 
there was no plastic exudation into the pupil. For thirty-six 
hours the dilatation of the i)upil by the use of the sulphate of 
atropia was imperfect, but gradually increasing. Its use for the 
first hour produced about one-fourth the normal effect. 

The sight was very much affected, the patient seeing every ob- 
ject as though in a dense fog. The treatment was commenced 
by the simple use of a solution of the sulphate of atropia, drop- 
ping one or two drops into the eye every three hours, and the 
rubbing into the temple of a small quantity of mercurial and bel- 
ladonna ointment twice a day. The next morning after the treat- 
ment was commenced, the pupil was found to be dilated to about 
one-third of its capacity, but remained circular, which 

was the only decidedly favorable symptom in the case. After the 
first tweuty-four hours there was no more pain. In three or four 
days the pupil was perfectiy dilated, and all the symptoms im- 
proving rapidly. 

At the end of nine days the patient left to join his ship. The 
inflammation had almost entirely subsided, and the sight was res- 
tored to nearly the normal standard, allowing for the effect of the 
sulphate of atropia on the sight. 

Remarlcs. — Although this was a severe case of iritis and had exist- 
ed for a week, still the absence of plastic exudation into the pupil, 
and the fact that the ciliary body and the choroid were not involved, 
wcje considered to be suflicient reasons for omitting the use of 



CLINICAL MEMORANDA —MEDICAL. 



81 



mercury. Tlioiigli the atropia only attained its maximum effect 
after about three clays, still the pupil remained circular from the 
first. Had the dilatation been irregular, I should not have hesi- 
tated to use mercmy. Had it not dilated at all or not reached a 
high'point of dilatation in a reasonably short time, mercury would 
have been indicated also. Had there been any other manifesta- 
tion of syphilis it would have been proper to give a mild course 
of mercury, having due reference to the bad condition of the 
I)atient's health. The cause of the iritis in this case was obscure, 
and though the evidence was in favor of a syphilitic origin, its 
history did not coincide well with what is absolutely known of 
syphilitic iritis. 

Case 4. — Keratitis and Iritis. — H. R., thirty-five years old, 
presented himself at the clinic for treatment on the 25th Novem- 
ber, 1867. Two months before he had had a severe attack of 
yellow fever. He had a relapse and was confined to the house 
for a month. About the 1st of i^ovember his left eye began to be 
sensitive when exposed to light or air. His eye became red and 
there was an excessive secretion of tears. He had at that time 
some pain, which he thought to be on the inner surface of the 
upper lid. There was no circumorbital pain. About'two weeks 
since the sight began to be affected. When he presented himself 
for treatment, there was a moderate degTce of catarrhal conjunc- 
tivitis, and some superficial ulceration of the outer and lower part 
of cornea, which extended to about its middle. The ulceration 
amounted over a part of the surface to a simple abrasion of the 
epithelium. The ulcerated surface of the cornea was somewhat 
vascular. There was present the usual zone of redness around 
the cornea, with a preponderance of the conjunctival over the 
subconjunctival redness. The cornea was slightly hazy for some 
distance around the ulcerated surface. The aqueous humor was 
turbid and the iris changed in color and swollen, The sight was 
much affected, the patient only being able to count fingers at 
twelve or fourteen feet. There were considerable pain (circum- 
orbital) and photophobia. To the above symptoms are to be 
added the usual symptoms of a mild chronic catarrhal conjunc- 
tivitis. 

There had been no medical treatment used. The patient's 

n 



82 



CLINICAL MEMOEANDA 



—MEDICAL, 



" landlord " had prescribed a wash of lead and zinc" which had 
caused a moderate deposit of lead in the ulcerated cornea. 

The extent of the affection of the iris was revealed by the use 
of atropia. At least half of the pupillary margin was found to be 
adherent to the capsule of the lens, and it was evident that the 
exudations were of such strength that they could not be brolien 
uj) by medical treatmei t. 

The patient was broken in health, and it was thought advisable 
not to use mercury internally. The internal treatment was 
limited to the use of vegetable tonics. A few drops of a solution 
of the sulphate of atropia were poured into the eye every three 
hours, and mercurial and belladonna ointment rubbed into the 
temple. The eye was well shaded and the patient kept quiet. 
In two days all pain had ceased, and the violence of the disease 
had begun to subside. In about a month he commenced work 
again by gas light, which caused a relapse which was soon re- 
lieved. After the violent symptoms of the disease had ceased, 
which was in a few days after the commencement of the treat- 
ment, I applied a weak solution of the nitrate of silver to the 
palpebral conjunctiva. This seemingly irritant treatment, by con- 
trolling the catarrhal symptoms, imj)roved the general condition 
of the eye. 

Bemarlcs. ^It was impossible to discover any cause for the 
iritis except the corneal trouble, which in the broken down con- 
dition of the patient's health was in my opinion sufficient to ac- 
count for its existence. The patient had been previously healthy 
and had never had an attack of rheumatism or syphilis. It is 
not uncommon to see cases of superficial affection of the cornea, 
if extensive, result in iritis, especially where the health has been 
broken by fever. Shortly after he came to me, the other eye be- 
came affected with slight catarrhal conjunctivitis, but the cornea 
and iris remained unaffected. As a rule the iris does not become 
implicated except the ulceration be deep or extensive j here the 
ulceration was not deep but there was probably implication of 
the deeper layers of the cornea in the inflammatory process. It 
was noted that the inflammation of the iris and its adhesions to 
the capsule of the lens were most marked at that part correspond- 
ng to the corneal disease. It was evidently one of those cases 



CLINICAL MEMOEAXDA.— MEDICAL. 



83 



whichj if neglected or mistreated, result in tlie formation of 
hypopyon. The pus in the great majority of cases comes from the 
cornea (posterior surface of) and not from the iris as many sup. 
pose. In fact I have known pus to form in the anterior chamber 
before there was a marked participation of the iris, and in one 
case hut little reaction on the part of the iris while the pus re- 
mained. The excision of a portion of the iris was proposed to 
the i)atient at the close of the medical treatment. This was not 
to admit light, for the cornea immediately over the pupil had 
cleared, the pupil itself was free, and the sight was very good. It 
has been observed, however, that if extensive and permanent ad- 
hesion take place between the iris and lens capsule, the acute 
disease terminates in chronic iritis or irido-choroiditis, which 
diseases in a large majority of cases terminate in the permanent 
injury or loss of the eye. The patient was relieved of the attack 
but declined the operation. 

Case 5th. — Keratitis and Iritis. — This patient was a child of 
four years old, small for his age, and quite pale and thin. He had 
been suffering for some time with an undecided form of intermit- 
tent fever of the quotidian type. The cold stage of the fever was 
but slightly marked. The child was very restless, especially at 
night, when it slept very little. When it was brought to the 
clinic, the left eye was affected with mild catarrhal conjunctivitis, 
and a superficial and moderately large ulceration of the upper 
part of the cornea. The corneal tissue for a considerable distance 
around the ulceration was slightly infiltrated aud moderately 
opaque. The cornea in the same area seemed slightly distended, 
as though its tissue had been softened by the inflammatory x^ro- 
cess. The ulcerated surface had a dirty greyish macerated ap- 
appearance. The iris was congested and the aqueous slightly 
turbid. In a couple of days after the child was brought to the 
clinic a small quantity of pus was observed at the lower -pavt of 
the anterior chamber. Previous to the appearance of the pus in 
tlie anterior chamber, the iritis was slight, but now became the 
most prominent aud important feature in the case. 

The tieatment consisted in the use of quinine, with reference to 
the fever at first, and subsequently as a simple tonic. A solution of 
the sulphate of atropia was used from the first. When the iritis 



84 



CLINICAL MEMOKANDA, 



—MEDICAL. 



became marked tlie use of small doses of calomel repeated five or 
six times a day was added to tlie treatment. After several days 
tlie fever was entirely broken, but the cliild, tbougli improved in 
liealthj did not regain strength as was desirable. Worms being 
suspected a vermifuge was administered. The following day 
they were passed in large quantities. This treatment was re- 
peated two or three times and with benefit to the condition of the 
child. Shortly after it had an attack of dysentery, the treatment 
for which caused it to pass a considerable quantity of worms 
again. The condition of the patient's health and the variety of 
affections of the eye made the i)rognosis extremely doubtful. In 
spite of the greatest care the disease advanced in intensity for at 
least ten days, but then gTadually yielded, and after six weeks 
no trace was left, except a nebulous opacity of the upper part of 
the cornea. The pus remained in the anterior chamber, pretty 
much as first seen, for two weeks, and then gradually disap- 
peared. As soon as the iris dilated tolerably well from the use 
of the atroi)ia, the mercury was discontinued. 

BemarTis. — This like Case 4, illustrates the danger of a seem- 
ingly unimportant affection of the cornea becoming complicated 
by iritis in certain conditions of health. It is highly probable 
that in both these cases the disease of the conjunctiva was the 
commencing trouble, and that the corneal disease was a conse- 
quence of it, as the iritis was the result of the inflammation of 
the cornea. It was found beneficial now and then to touch the 
palpebral conjunctiva with a weak solution of the nitrate of sil- 
ver, even when the pus was still present in the anterior chamber. 
Ordinarily, of course, this would only increase the iritis, but here 
the corneal affection being the source of irritation to the iris, any 
thing which would diminish the former would in all probability 
benefit the latter. Of course this practice is only recommended 
in cases where the conjunctival disease is the starting point, and 
its continuance evidently increases the dangers of the case. The 
greatest caution in its use is therefore recommended. In all 
affections of the cornea where there is the slightest suspi- 
cion of a participation of the iris in the disease, the sulphate of 
atropia is absolutely indicated. The presence of a very moderate 
amount of pus in the anterior chamber does not demand a change 



CLIKICAL MEMORANDA.— MEDICxlL. 



85 



of treatment. Should tlie amount be very great and increasing, 
the indication is to evacuate it through an opening in the cornea. 
If the operation be performed when there is but a small accumu- 
lation of pus, it is generally unnecessary and may be very perni- 
cious. Only one case has presented itself at the clinic, since it 
was established, in which the operation for the removal of the 
pus was indicated. As a rule the appropriate treatment for the 
diseases of the cornea and iris will lead to its absorption. 



Ae-T. XII.~Chemical Examination in a case of Fatal Poisoning hy 
Stramonium : By J. W. Mallet, Ph. D., M. D., Professor of 
Chemistry, University of Louisiana. 

In the early part of March of the present year, a box was received 
at the chemical laboratory of the Medical Department, University 
of Louisiana, sent from Mississippi, by Dr. E. J. Durr, of that 
State, and containing a sealed bottle, in which were the stomach 
and its contents of a young man supposed to have died from the 
effects of poison. 

The accompanying letter requested a chemical examination, 
stating that no distinct clue to the nature of the poison used (if 
there had been any) could be given j that the young man in ques- 
tion had assisted in getting up a party, arrived late at the house 
at which the party was given, and was served with sujiper — 
which was saved for him — apart from the other guests j that he 
felt no sickness until about an hour after supper, when, as he was 
dancing, he felt sick, went out upon the gallery, vomited, and 
complained of headache — it is said that the pupils of his eyes 
were dilated, this fact not ascertained by the physician himself — 
that shortly afterwards the patient fell into a stupor, went to 
sleep, and was not noticed till after midnight, when, being 
aroused to go home, he was almost unconscious, with a slow, full 
and labored pulse. He died the next morning about nine o'clock. 
No mental excitement had been noticed, the patient x)assing into 
a semi-comatose condition as soon as affected by the poison, and 
ceasing to be rational after three or four hours. He was de- 
scribed as having been limber," and in a cold, clammy perspi- 
ration. There had been no purging, but vomiting had continued 



86 



CLIKICAL MEMOKANDA.— MEDICAL. 



for some time. There liad been no complete post-mortem exami- 
nation ; the stomach and part of the duodenum had simply been 
removed and put aside for examination. 

The stomach was opened, and found to contain nothing but a 
small quantity of a tolerably liquid reddish-brown matter resem- 
bling coffee grounds. There was no clearly marked morbid ap- 
pearance about the inner surface of the organ itself. 

The stomach, cut into fragments, and the contents were sepa- 
rately examined by the method proposed by Stas, namely, treat- 
ment with water and alcohol successively, with the addition of a 
few drops of sulphuric acid, evaporation at a very gentle heat 
over a water bath, digestion of the dried residues with water, 
and, after filtration and the addition of caustic potash enough to 
l^roduce alkaline reaction, agitation of the aqueous solution with 
ether. In one experiment ether alone was used as the final 
solvent, in another a mixture of ether and chloroform. 

A residue was left from the spontaneous evaporation of the 
etherial solution, in clearly recognizable quantity (probably J or 
J grain) from the contents of the stomach — in traces only from the 
stomach itself. This residue crystallized readily upon a glass 
slide, and under the microscope presented the appearance of 
minute prisms, aggregated together in pennate and stellate 
groups. It could easily be redissolved and recrystallized. A 
minute particle placed upon the tongue gave rise to a well-marked 
bitter taste. Dissolved in water it produced a distinct alkaline 
reaction with reddened litmus paper. Its aqueous solution gave 
l^recipitates with tannic acid and mercuro-iodide of i)otassium. 
Kitric acid produced no marked coloration j sulphuric acid a red 
coloration, vergiug rather upon orange than rose-color, but the 
quantity used was not sufificient for any distinct observation. 

Dr. Pope, in charge of the eye and ear clinic of the Universitj^, 
was kind enough to make a careful experiment as to the effect of 
this substance upon the eye. After noticing that the pupils of 
the writer's eyes were of equal size when similarly exposed to 
light, a very minute portion of the residue from the evaporation 
of the solution in ether was introduced beneath the lid of one 
eye, and the result was awaited in a partially darkened room. 
In about half an hour distinct and strongly marked dilatation of 
the pupil was produced j a fact verified by Drs. Stone, Pope^ 



CLIXICAL MEMOEANDA.— MEDICAL. 



87 



Hawthorn and others. The power of accommodation of the eye 
to varying distances was interfered with, but to a small extent 
only. In three or four hours all effect upon* the eye had passed 
away. 

As the result of the above experiments, it was considered as 
proved beyond doubt that the stomach examined did really con- 
tain a x)oisonous alkaloid of the atropine group. It appeared most 
probable that this alkaloid was either atropine itself or daturine, 
and the latter seemed to be pointed to more particularly by — j 

1st. The readiness Avith which the substance found could be 
crystallized, atropine being notoriously of difficult crystallization. 

2d. The short duration of the effect upon the pupil of the eye, 
though this was so strongly marked while it lasted. It is stated 
in Bouchardat's Annuaire de Therapeutique for 1864, p. 21, 
as the main result of a comparison of the physiological effects 
of daturine and atropine (beheved by most authorities to be 
chemically the same) that the general action of the former poison 
is more intense and less persistent than that of the latter, and 
as regards the eye, that daturine dilates the pupil more rapidly 
than atropine, but the dilation does not last so long. 

3d. — The fact that datura stramonium or Jamestown T^^eed" 
is well known to negroes as a poison, is everywhere accessible to 
them, and is used by them for criminal purposes — while bella- 
donna in any form is much less known and procurable. 

Suspicion had been directed to negroes in this case. 

A report, stating these results in form for legal use, was for- 
warded to Mississippi. 

Since then a letter has been received from Dr. Durr, confirma- 
tory of the conclusions arrived at. He states that a negro man 
and woman had been arrested on suspicion of their having been 
guilty of the act of poisoning, and that they had confessed to 
having used stramonium. 

Memoranda icith reference to reparation of PercJiJoric Acid and 
Ferclilorates for medicinal use. 

The very large proportion of oxygen contained in perchloric 
acid, and the remarkable stability presented by this substance 
and the salts which it forms, suggested the idea of examining the 
therapeutic effects which might be obtained by means of them. 



88 



CLINICAL MEMOEANDA.— MEDICAL. 



This idea occurred without a knowledge of anything having pre- 
viously been attempted in the same direction, although it must 
be confessed that no special search was made in medical litera- 
ture with reference to the point. 

The substances prepared were, the acid itself, and its com- 
pounds with potash, sesqui-oxide of iron, bismuth and quinine. 

Perchlorate of potash was first formed, by heating successive 
portions of chlorate of potash in a large porcelain crucible over a 
gas lamp, raising the temperature gradually until the melted salt 
began to give off oxygen freely, then maintaining steadily the 
same degree of heat as long as effervescence continued. The 
residual mass was crushed, washed moderately with cold water, 
dissolved in boiling water, crystallized by tolerably rapid cool- 
ing, and purified by two or three rapid crystallizations. As thus 
obtained, the salt was supplied to Dr. S. M. Bemiss for trial in 
the wards of the Charity Hospital, any possible danger from its 
use having been guarded against by preliminary experiments 
with large doses administered to the lower animals. 

For the purpose of preparing perchloric acid in the free state 
the perchlorate of potash was carefully distilled, in small quanti- 
ties at a time, with sulphuric acid diluted with but little water. 
A portion of the perchloric acid underwent decomposition, but 
the greater part was collected, in a tolerably concentrated form. 
Its exact strength was not determined, but that which was pre- 
pared for trial in the hospital was diluted until it could be borne 
in small quantity in the mouth, but had a very strong sour taste. 

For perchlorate of iron, the sesqui-chloride of the metal was 
precipitated by a slight excess of ammonia, the hydrated sesqui- 
oxide of iron was washed twice or thrice by decantation, and was 
then added to somewhat diluted aqueous perchloric acid as long- 
as it was dissolved. The solution was filtered and preserved for 
use. 

The perchlorates of bismuth and quinine were prepared in a 
similar way, using the precipitated hydrated oxide of bismuth 
and freshly precipitated quinine respectively. 

It was intended to use these solutions merely for the purpose of 
ascertaining whether any distinct therapeutic effect could be ob- 
tained from them, and, if so, its general nature. It was proposed, 



CLINICAL MEMORANDA — MEDICAL. 



iu case these first experiments funiislied any encoiuagemeut to 
proceed, to prepare several otlier compounds of percliloric acid, 
to try different forms and veliicles of administration, and especi- 
ally to note the precise quantitative composition of the different 
salts and the strength of the solutions used, so that there should 
be some precision in the doses employed. The writer was obliged 
to leave these experiments incomplete on leaving Xew Orleans at 
the close of the session. 

The following statements bearing on this niatter ha\'e since 
been noticed as already on record : 

Bodecker, in 18^9, prepared the percldorates and i)er-iodates of 
several of the alkaloids, including the per cldorates of quinine and 
cinchonine. Their chemical characters were described by him, 
and their crystalline forms by Dauber ; but no allusion was made 
to their phy siological action.— .4 d. Cheui. u. Fharm^ 71-50. 

Itecently, the chlorate of quinine has been prepared, at the re- 
(|uest of Dr. Lyons, for some experiments performed at the Whit- 
worth Hospital, Dublin, in connexion with two or three cases of 

black death/^ It is said to have been siuce employed by that 
gentleman with great success as a new febrifuge, reference being 
made to Dr. Lyons' clinic (Medical Press and Circulai', n oI. 1. p. 

653). Mr. Chas. K. C. Tichborne described, in a paper read before 
the British Pharmaceutical Conference, the method of preparation 
and chemical properties of this salt, and stated the results of its 
analysis. He remarks, that for the internal administration of 
this salt it is soluble enough in water (probably the most eflica- 
cious method of exhibiting it). It is incompatible with the mine- 
ral acids, as they form the ordinary salts of quinine ; it is for this 
reason that Dr. Lyons has hitherto prescribed it in conjunction 
with ;gerclilorie acid, lUeJf a valuable Qxu\izev,-^Chcnucnl Xews, 
Xo. 35, {Sept 7, 1866,) ^j. 111. 

Addendoi.— The medicines whose mode of preparation Prof. 
Mallet has described, were not used in a sufiScient number of 
cases to justify any conclusions, based upon actual observation, in 
respect to their therapeutic value. 

Perchlorate of potash was given in from five to ten grain doses, 
dissolved in water, thrice daily. It was prescribed for sub acute 
rheumatism, and for one case of anaemia, with enlarged spleen. 
n 



CLIKICAL MEMOEAKDA.— MEDICAL. 

Perchloric acid was given in fifteen grain doses; in sweetened 
water or infnsion of a vegetable bitter, three times daily, for 
about one week, to the patient with lardaceous liver and to a 
l)atient with anorexia and malarial cachexia for about the same 
time. Pepsine could not be procured, and this medicine was 
used to meet the deficiency. 

Perchlorate of iron was given in doses of 3ss to 3i, thrice daily, 
to two cases of antemia from malarial influence. 

Perchlorate of bismuth was given in doses of ten to fifteen 
drops, in diarrhoea and dyspepsia. 

Perchlorate of quinine was given in 5i doses, thrice dail}^, to 
several cases of inveterate chill and fever. 

The most marked good results were obtained from the i)erchlo- 
rate of bismuth, perchlorate of quinine and perchlorate of iron, 
respectively mentioned in the order of their apparent value. In 
the publication of 1869 it is hoped that the joint experience of 
our Faculty' may authorize the announcement of more definite 
conclusions in regard to the value of these preparations. 

S. M. Bemiss. 



\ 



lliiliiil^ CONGRESSp 

021 623 831 A 



I TRRARY OF CONGRESS 

IHHB 

021 623 831 ft • 



